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
Q1: A 68-year-old male with idiopathic pulmonary fibrosis (FVC 45% predicted, DLCO 35%
predicted) presents for open right hemicolectomy for colon cancer. He is on home oxygen at 2
L/min and has pulmonary hypertension (estimated RVSP 55 mmHg). Which anesthetic strategy
best optimizes his perioperative risk?
A. General anesthesia with high tidal volumes (10-12 mL/kg) to prevent atelectasis in the
dependent lung
B. Combined epidural-general anesthesia with low tidal volume ventilation (6 mL/kg) and
permissive hypercapnia
C. Spinal anesthesia with heavy sedation to avoid intubation
D. General anesthesia with nitrous oxide to reduce hypoxic pulmonary vasoconstriction
Correct Answer: B
Rationale: Combined epidural-general anesthesia with lung-protective ventilation is optimal for
this patient with severe interstitial lung disease and pulmonary hypertension. Key
discriminators: (1) High tidal volumes (Option A) cause volutrauma and exacerbate ventilator-
induced lung injury in restrictive lung disease; (2) Permissive hypercapnia must be used
cautiously in pulmonary hypertension but is preferable to high-pressure ventilation; (3) The
epidural reduces systemic vascular resistance and right ventricular afterload while providing
excellent analgesia to prevent splinting; (4) Nitrous oxide (Option D) is contraindicated due to its
pulmonary vasoconstrictive effects and expansion of airspaces in bullous lung disease; (5) Spinal
anesthesia (Option C) risks precipitous hypotension and respiratory compromise in a patient
unable to lie flat comfortably. Recent studies in Anesthesiology (2024) demonstrate improved
outcomes in ILD patients using neuraxial techniques combined with protective ventilation
strategies.
Q2: A 72-year-old female with severe aortic stenosis (valve area 0.7 cm², mean gradient 45
mmHg, EF 35%) and atrial fibrillation presents for urgent femoral neck fracture repair. Her INR is
2.8 on warfarin. Which management sequence is most appropriate?
,A. Proceed immediately with spinal anesthesia; therapeutic INR acceptable for neuraxial
technique in emergent orthopedic surgery
B. Reverse warfarin with 4-factor PCC and vitamin K, delay surgery 12-24 hours, then proceed
with general anesthesia
C. Proceed with general anesthesia without reversal; accept bleeding risk given urgency
D. Administer fresh frozen plasma immediately and proceed with spinal anesthesia
Correct Answer: B
Rationale: The correct sequence balances thromboembolic risk against neuraxial hematoma risk
while optimizing hemodynamics. Key discriminators: (1) Therapeutic INR (2.8) is an absolute
contraindication to neuraxial techniques per ASRA guidelines (Option A); (2) Femoral neck
fracture repair is urgent but not emergent—12-24 hour delay for reversal is acceptable; (3) 4-
factor PCC rapidly reverses warfarin (within 1 hour) compared to FFP (Option D), which requires
large volumes and risks TACO in AS patients; (4) Proceeding without reversal (Option C) risks
catastrophic bleeding in a patient who cannot tolerate acute anemia due to fixed cardiac
output; (5) General anesthesia allows better hemodynamic control (avoidance of hypotension)
than spinal in severe AS. The 2023 AHA/ACC guidelines emphasize that "urgent" surgery permits
brief optimization to reduce procedural risk.
Q3: A 58-year-old male with Cushing's syndrome (cortisol 45 μg/dL, ACTH <5 pg/mL) secondary
to a 4 cm adrenal adenoma presents for laparoscopic adrenalectomy. Preoperative optimization
reveals hypokalemia (K+ 2.8 mEq/L) and glucose intolerance (HbA1c 8.2%). Which preoperative
intervention is most critical?
A. Immediate surgery; delay risks adrenal carcinoma transformation
B. Initiate spironolactone 100 mg BID, correct potassium to >3.5 mEq/L, optimize glucose with
insulin, delay 7-14 days
C. Administer stress-dose hydrocortisone preoperatively to prevent adrenal crisis
D. Start metyrapone to reduce cortisol production, delay surgery 4-6 weeks
Correct Answer: B
Rationale: Optimization of metabolic derangements takes precedence over rapid surgical
intervention. Key discriminators: (1) Severe hypokalemia increases risk of perioperative
arrhythmias and neuromuscular weakness; spironolactone addresses both potassium wasting
and hypertension; (2) Glucose optimization reduces infection risk and improves wound healing;
(3) Stress-dose steroids (Option C) are unnecessary preoperatively in primary adrenal
Cushing's—the contralateral adrenal is suppressed but functional; (4) Metyrapone (Option D) is
reserved for patients unfit for surgery or preoperative optimization of severe hypercortisolism,
, not routine cases; (5) 4 cm adenomas have low malignant potential; brief delay for optimization
is standard of care. The Endocrine Society Clinical Practice Guidelines (2023) recommend
preoperative medical optimization of Cushing's syndrome to reduce perioperative morbidity.
Q4: A 34-year-old female with systemic lupus erythematosus (SLE) on chronic prednisone 10 mg
daily presents for total hip arthroplasty. She has antiphospholipid syndrome with history of
DVT/PE, currently therapeutic on rivaroxaban. Her platelet count is 85,000/μL. Which anesthetic
plan is safest?
A. Continue rivaroxaban; perform general anesthesia with careful positioning
B. Bridge to unfractionated heparin, stop 4-6 hours preoperatively, use general anesthesia
C. Stop rivaroxaban 48 hours preoperatively, check anti-Xa level, proceed with spinal anesthesia
if normal
D. Continue rivaroxaban; spinal anesthesia with traumatic needle placement is safe with platelet
count >80,000
Correct Answer: B
Rationale: Bridging to short-acting heparin minimizes thromboembolic risk while allowing safe
neuraxial technique avoidance. Key discriminators: (1) Thrombocytopenia (85,000) combined
with anticoagulation makes neuraxial techniques high-risk for epidural hematoma; (2)
Rivaroxaban must be stopped 48-72 hours before neuraxial techniques (Option C), but bridging
is required given high thromboembolic risk (antiphospholipid syndrome with prior events); (3)
Continuing rivaroxaban (Options A, D) risks excessive surgical bleeding in major orthopedic
surgery; (4) General anesthesia eliminates neuraxial hematoma risk; unfractionated heparin
allows rapid reversal if needed. The ASRA 4th Edition Consensus Guidelines (2024) specifically
address antiphospholipid syndrome as a high-risk condition requiring individualized bridging
strategies.
Q5: A 45-year-old male with severe hemophilia A (factor VIII <1%) presents for emergency
appendectomy. He has high-titer inhibitors (Bethesda titer 12 BU) and failed previous immune
tolerance therapy. Which perioperative management strategy is most appropriate?
A. Administer recombinant factor VIII concentrate 100 U/kg preoperatively
B. Use recombinant activated factor VII (rFVIIa) 90 μg/kg every 2 hours perioperatively
C. Administer emicizumab (Hemlibra) 3 mg/kg IV immediately preoperatively
D. Use plasma-derived factor VIII concentrate with activated prothrombin complex concentrate
(aPCC) rescue
PRACTICE EXAM V2 2026/2027 | Verified Questions and
Answers | Distinct Clinical Scenarios from V1 | For
Specialized Certification & Board Review | Grade A
Target | Pass Guaranteed
Q1: A 68-year-old male with idiopathic pulmonary fibrosis (FVC 45% predicted, DLCO 35%
predicted) presents for open right hemicolectomy for colon cancer. He is on home oxygen at 2
L/min and has pulmonary hypertension (estimated RVSP 55 mmHg). Which anesthetic strategy
best optimizes his perioperative risk?
A. General anesthesia with high tidal volumes (10-12 mL/kg) to prevent atelectasis in the
dependent lung
B. Combined epidural-general anesthesia with low tidal volume ventilation (6 mL/kg) and
permissive hypercapnia
C. Spinal anesthesia with heavy sedation to avoid intubation
D. General anesthesia with nitrous oxide to reduce hypoxic pulmonary vasoconstriction
Correct Answer: B
Rationale: Combined epidural-general anesthesia with lung-protective ventilation is optimal for
this patient with severe interstitial lung disease and pulmonary hypertension. Key
discriminators: (1) High tidal volumes (Option A) cause volutrauma and exacerbate ventilator-
induced lung injury in restrictive lung disease; (2) Permissive hypercapnia must be used
cautiously in pulmonary hypertension but is preferable to high-pressure ventilation; (3) The
epidural reduces systemic vascular resistance and right ventricular afterload while providing
excellent analgesia to prevent splinting; (4) Nitrous oxide (Option D) is contraindicated due to its
pulmonary vasoconstrictive effects and expansion of airspaces in bullous lung disease; (5) Spinal
anesthesia (Option C) risks precipitous hypotension and respiratory compromise in a patient
unable to lie flat comfortably. Recent studies in Anesthesiology (2024) demonstrate improved
outcomes in ILD patients using neuraxial techniques combined with protective ventilation
strategies.
Q2: A 72-year-old female with severe aortic stenosis (valve area 0.7 cm², mean gradient 45
mmHg, EF 35%) and atrial fibrillation presents for urgent femoral neck fracture repair. Her INR is
2.8 on warfarin. Which management sequence is most appropriate?
,A. Proceed immediately with spinal anesthesia; therapeutic INR acceptable for neuraxial
technique in emergent orthopedic surgery
B. Reverse warfarin with 4-factor PCC and vitamin K, delay surgery 12-24 hours, then proceed
with general anesthesia
C. Proceed with general anesthesia without reversal; accept bleeding risk given urgency
D. Administer fresh frozen plasma immediately and proceed with spinal anesthesia
Correct Answer: B
Rationale: The correct sequence balances thromboembolic risk against neuraxial hematoma risk
while optimizing hemodynamics. Key discriminators: (1) Therapeutic INR (2.8) is an absolute
contraindication to neuraxial techniques per ASRA guidelines (Option A); (2) Femoral neck
fracture repair is urgent but not emergent—12-24 hour delay for reversal is acceptable; (3) 4-
factor PCC rapidly reverses warfarin (within 1 hour) compared to FFP (Option D), which requires
large volumes and risks TACO in AS patients; (4) Proceeding without reversal (Option C) risks
catastrophic bleeding in a patient who cannot tolerate acute anemia due to fixed cardiac
output; (5) General anesthesia allows better hemodynamic control (avoidance of hypotension)
than spinal in severe AS. The 2023 AHA/ACC guidelines emphasize that "urgent" surgery permits
brief optimization to reduce procedural risk.
Q3: A 58-year-old male with Cushing's syndrome (cortisol 45 μg/dL, ACTH <5 pg/mL) secondary
to a 4 cm adrenal adenoma presents for laparoscopic adrenalectomy. Preoperative optimization
reveals hypokalemia (K+ 2.8 mEq/L) and glucose intolerance (HbA1c 8.2%). Which preoperative
intervention is most critical?
A. Immediate surgery; delay risks adrenal carcinoma transformation
B. Initiate spironolactone 100 mg BID, correct potassium to >3.5 mEq/L, optimize glucose with
insulin, delay 7-14 days
C. Administer stress-dose hydrocortisone preoperatively to prevent adrenal crisis
D. Start metyrapone to reduce cortisol production, delay surgery 4-6 weeks
Correct Answer: B
Rationale: Optimization of metabolic derangements takes precedence over rapid surgical
intervention. Key discriminators: (1) Severe hypokalemia increases risk of perioperative
arrhythmias and neuromuscular weakness; spironolactone addresses both potassium wasting
and hypertension; (2) Glucose optimization reduces infection risk and improves wound healing;
(3) Stress-dose steroids (Option C) are unnecessary preoperatively in primary adrenal
Cushing's—the contralateral adrenal is suppressed but functional; (4) Metyrapone (Option D) is
reserved for patients unfit for surgery or preoperative optimization of severe hypercortisolism,
, not routine cases; (5) 4 cm adenomas have low malignant potential; brief delay for optimization
is standard of care. The Endocrine Society Clinical Practice Guidelines (2023) recommend
preoperative medical optimization of Cushing's syndrome to reduce perioperative morbidity.
Q4: A 34-year-old female with systemic lupus erythematosus (SLE) on chronic prednisone 10 mg
daily presents for total hip arthroplasty. She has antiphospholipid syndrome with history of
DVT/PE, currently therapeutic on rivaroxaban. Her platelet count is 85,000/μL. Which anesthetic
plan is safest?
A. Continue rivaroxaban; perform general anesthesia with careful positioning
B. Bridge to unfractionated heparin, stop 4-6 hours preoperatively, use general anesthesia
C. Stop rivaroxaban 48 hours preoperatively, check anti-Xa level, proceed with spinal anesthesia
if normal
D. Continue rivaroxaban; spinal anesthesia with traumatic needle placement is safe with platelet
count >80,000
Correct Answer: B
Rationale: Bridging to short-acting heparin minimizes thromboembolic risk while allowing safe
neuraxial technique avoidance. Key discriminators: (1) Thrombocytopenia (85,000) combined
with anticoagulation makes neuraxial techniques high-risk for epidural hematoma; (2)
Rivaroxaban must be stopped 48-72 hours before neuraxial techniques (Option C), but bridging
is required given high thromboembolic risk (antiphospholipid syndrome with prior events); (3)
Continuing rivaroxaban (Options A, D) risks excessive surgical bleeding in major orthopedic
surgery; (4) General anesthesia eliminates neuraxial hematoma risk; unfractionated heparin
allows rapid reversal if needed. The ASRA 4th Edition Consensus Guidelines (2024) specifically
address antiphospholipid syndrome as a high-risk condition requiring individualized bridging
strategies.
Q5: A 45-year-old male with severe hemophilia A (factor VIII <1%) presents for emergency
appendectomy. He has high-titer inhibitors (Bethesda titer 12 BU) and failed previous immune
tolerance therapy. Which perioperative management strategy is most appropriate?
A. Administer recombinant factor VIII concentrate 100 U/kg preoperatively
B. Use recombinant activated factor VII (rFVIIa) 90 μg/kg every 2 hours perioperatively
C. Administer emicizumab (Hemlibra) 3 mg/kg IV immediately preoperatively
D. Use plasma-derived factor VIII concentrate with activated prothrombin complex concentrate
(aPCC) rescue
