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PGIM MD Anaesthesiology study materials
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PGIM MD Anaesthesiology practice questions

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Question 1General Anaesthesia and Airway Management

A 45-year-old man with a BMI of 42 kg/m² is scheduled for elective laparoscopic cholecystectomy under general anaesthesia. Preoxygenation is planned. Which manoeuvre most reliably improves functional residual capacity and delays desaturation during induction?

  1. Routine nasopharyngeal airway insertion before preoxygenation
  2. Application of 10 cmH2O positive end-expiratory pressure with the patient supine
  3. Head-up (25–30°) ramped positioning with tight-fitting mask preoxygenation Correct answer.
  4. Two minutes of tidal-volume breathing with a simple face mask at 6 L/min

Explanation

Ramped head-up positioning reduces abdominal pressure on the diaphragm, increases functional residual capacity and improves mask seal, so the safe apnoea time before desaturation is prolonged. Preoxygenation should be delivered with a tight seal and high inspired oxygen until end-tidal oxygen exceeds about 90%. A simple face mask does not reliably achieve this.

Question 2General Anaesthesia and Airway Management

During rapid sequence induction in a 70 kg adult, which dose of intravenous suxamethonium is most appropriate to achieve reliable intubating conditions?

  1. 10 mg
  2. 100 mg Correct answer.
  3. 50 mg
  4. 500 mg

Explanation

The standard intubating dose of suxamethonium is 1–1.5 mg/kg, which for a 70 kg adult is approximately 70–100 mg. This dose produces profound block within 45–60 seconds and lasts about 5–10 minutes. Lower doses give unreliable conditions and higher doses prolong paralysis without added benefit.

Question 3General Anaesthesia and Airway Management

A patient with a known difficult airway is being intubated awake with a flexible fibrescope. Which finding is the strongest indication to abandon the awake fibreoptic technique and proceed to a surgical airway?

  1. Inability to visualise the vocal cords on the first pass
  2. Copious secretions obscuring the view despite antisialagogue premedication
  3. Progressive airway obstruction with falling oxygen saturation during attempts Correct answer.
  4. Patient coughing during insertion of the scope

Explanation

The overriding principle in awake fibreoptic intubation is to maintain oxygenation and never allow the patient to reach a 'cannot intubate, cannot oxygenate' state. Progressive obstruction with desaturation is a failure of the chosen plan and mandates rescue, including a surgical airway if oxygenation cannot be restored. Secretions, coughing and a failed first view are manageable problems that do not by themselves require an emergency surgical airway.

Question 4General Anaesthesia and Airway Management

Which preoperative finding is the single best predictor of difficult mask ventilation in an adult surgical patient?

  1. Mallampati class I
  2. Age greater than 60 years
  3. Body mass index less than 25 kg/m²
  4. Presence of a beard Correct answer.

Explanation

Beard, edentulous state, obesity, snoring and age over 55 are recognised predictors of difficult mask ventilation, with beard and edentulism among the most consistent. A beard prevents an airtight seal between the mask and the face. Mallampati class and low BMI are not predictors of difficult mask ventilation.

Question 5General Anaesthesia and Airway Management

A 30-year-old woman requires emergency caesarean delivery under general anaesthesia. Which induction regimen best balances the need for rapid airway control against the risk of aspiration and fetal exposure?

  1. Thiopentone 5 mg/kg with cricoid pressure and suxamethonium 1.5 mg/kg Correct answer.
  2. Ketamine 2 mg/kg with atracurium 0.5 mg/kg
  3. Sevoflurane 8% inhalational induction with spontaneous ventilation
  4. Propofol 2.5 mg/kg with fentanyl 2 mcg/kg, then rocuronium 1.2 mg/kg

Explanation

Rapid sequence induction with a rapid-onset barbiturate and suxamethonium, together with cricoid pressure, is the classic technique for emergency caesarean section because it secures the airway quickly while limiting aspiration risk. Thiopentone is used at reduced dose (about 4–5 mg/kg) to limit fetal depression. Opioids are usually avoided before delivery because they readily cross the placenta.

Question 6General Anaesthesia and Airway Management

A patient is being ventilated through a laryngeal mask airway during a minor procedure. Which sign most strongly suggests that the device has rotated or seated poorly and is causing partial obstruction?

  1. End-tidal carbon dioxide of 38 mmHg
  2. A persistent audible leak with a low oropharyngeal leak pressure Correct answer.
  3. Peak airway pressure of 12 cmH2O with a square capnography waveform
  4. Bilateral equal breath sounds on auscultation

Explanation

A low oropharyngeal leak pressure with an audible leak indicates that the cuff is not sealing the pharynx, often due to malposition or rotation. Normal peak pressures, equal breath sounds and normal capnography suggest adequate ventilation. Leak pressure should generally exceed 20 cmH2O for a well-seated device.

Question 7General Anaesthesia and Airway Management

Which statement about the use of a videolaryngoscope with a hyperangulated blade for a predicted difficult airway is most accurate?

  1. It eliminates the need for a backup plan because intubation is always successful
  2. It requires less force and gives a better glottic view, but a stylet or channel is often needed to direct the tube Correct answer.
  3. It provides a better view only when the patient is fully paralysed
  4. It is contraindicated when mouth opening is limited to 2 cm

Explanation

Hyperangulated videolaryngoscope blades improve the glottic view with less cervical movement and force, but the tube must be shaped to match the blade's curve, usually with a stylet or a channeled device. A backup plan is always required because intubation can still fail. Limited mouth opening is a relative rather than absolute contraindication for many video devices.

Question 8General Anaesthesia and Airway Management

A 55-year-old man with severe aortic stenosis undergoes general anaesthesia. Which induction strategy is most appropriate to maintain coronary perfusion?

  1. Hyperventilation to a PaCO2 of 25 mmHg to reduce myocardial work
  2. Rapid bolus of propofol 3 mg/kg to secure the airway quickly
  3. Slow careful induction maintaining sinus rhythm, preload and systemic vascular resistance Correct answer.
  4. High-dose volatile agent to produce deep anaesthesia before intubation

Explanation

In severe aortic stenosis, cardiac output is fixed and coronary perfusion depends on an adequate diastolic pressure. Anaesthesia must preserve systemic vascular resistance, preload and sinus rhythm while avoiding tachycardia and hypotension. Rapid large boluses of propofol or high volatile concentrations cause vasodilation and drop perfusion pressure.

Question 9General Anaesthesia and Airway Management

During laryngoscopy, which manoeuvre is correctly described as applying backward, upward and rightward pressure on the thyroid cartilage to improve the view of the larynx?

  1. Jaw thrust
  2. Sellick manoeuvre
  3. BURP manoeuvre Correct answer.
  4. Head tilt-chin lift

Explanation

The BURP manoeuvre applies backward, upward and rightward pressure on the thyroid cartilage to bring the larynx into view during difficult laryngoscopy. The Sellick manoeuvre is cricoid pressure applied to prevent aspiration. Jaw thrust and head tilt-chin lift are basic airway-opening manoeuvres.

Question 10General Anaesthesia and Airway Management

A patient with a known difficult airway becomes apnoeic and cannot be intubated after several attempts. Oxygen saturation is falling despite mask ventilation and a supraglottic airway has failed. Which sequence is most appropriate?

  1. Insert a second supraglottic airway and continue ventilation attempts
  2. Continue further intubation attempts with a different blade
  3. Proceed to emergency front-of-neck access without delay Correct answer.
  4. Administer a further dose of neuromuscular blocker and wait

Explanation

Once a 'cannot intubate, cannot oxygenate' situation is recognised, further attempts at intubation or supraglottic rescue waste time while hypoxia progresses. Emergency front-of-neck access, such as a scalpel-bougie-tube technique, should be performed without delay. Waiting for a neuromuscular blocker to wear off is not appropriate in a hypoxic patient.

Question 11General Anaesthesia and Airway Management

Which of the following best describes the mechanism by which a supraglottic airway provides a seal during positive pressure ventilation?

  1. It occludes the oesophagus to prevent regurgitation
  2. It seals the trachea below the vocal cords
  3. It forms a low-pressure seal around the laryngeal inlet in the hypopharynx Correct answer.
  4. It seals the nasopharynx above the soft palate

Explanation

Supraglottic airways sit in the hypopharynx and form a low-pressure seal around the laryngeal inlet, allowing positive pressure ventilation. They do not enter the trachea and do not reliably protect against aspiration. They do not seal the nasopharynx.

Question 12General Anaesthesia and Airway Management

A patient undergoing general anaesthesia has a history of malignant hyperthermia susceptibility. Which inhalational agent is safest to use?

  1. None of the volatile agents Correct answer.
  2. Isoflurane
  3. Sevoflurane
  4. Desflurane

Explanation

All volatile anaesthetic agents are triggers for malignant hyperthermia in susceptible patients. A trigger-free technique using total intravenous anaesthesia with propofol and a non-triggering neuromuscular blocker such as rocuronium is required. Volatile agents must be avoided, and the machine should be flushed or a clean circuit used.

Question 13General Anaesthesia and Airway Management

A 65-year-old smoker with chronic obstructive pulmonary disease is undergoing general anaesthesia. Which ventilatory strategy best reduces the risk of dynamic hyperinflation?

  1. Long expiratory time with a low respiratory rate and low tidal volume Correct answer.
  2. Application of high positive end-expiratory pressure regardless of auto-PEEP
  3. High tidal volume to overcome airway resistance
  4. Short inspiratory time with a high respiratory rate

Explanation

In obstructive lung disease, expiratory flow limitation means that a long expiratory time allows complete exhalation and prevents gas trapping. A low respiratory rate, small tidal volume and long expiratory time reduce dynamic hyperinflation. High respiratory rates and high PEEP worsen air trapping when auto-PEEP is present.

Question 14General Anaesthesia and Airway Management

Which nerve block is most appropriate for awake fibreoptic intubation to suppress the gag reflex and airway stimulation?

  1. Superficial cervical plexus block
  2. Glossopharyngeal nerve block combined with topical local anaesthetic to the airway Correct answer.
  3. Bilateral superior laryngeal nerve block only
  4. Inferior alveolar nerve block

Explanation

Awake airway instrumentation requires topical anaesthesia of the nasal or oral mucosa, oropharynx and larynx, often supplemented by glossopharyngeal nerve block to suppress the gag reflex. Superior laryngeal nerve block alone anaesthetises only the supraglottic larynx and does not abolish gagging. Inferior alveolar and cervical plexus blocks do not anaesthetise the airway.

Question 15General Anaesthesia and Airway Management

A patient is undergoing rapid sequence induction. Which action best reduces the risk of aspiration during induction?

  1. Applying cricoid pressure from the start of induction until the airway is secured Correct answer.
  2. Maintaining spontaneous ventilation until the airway is secured
  3. Placing the patient in the Trendelenburg position
  4. Ventilating with high tidal volumes before intubation

Explanation

Cricoid pressure compresses the oesophagus against the vertebral body and is applied from the onset of induction until the airway is secured and the cuff inflated. Avoiding positive pressure ventilation before intubation also reduces gastric insufflation. Trendelenburg positioning does not prevent aspiration.

Question 16General Anaesthesia and Airway Management

Which finding on preoperative airway assessment most strongly predicts difficult direct laryngoscopy?

  1. Mallampati class II with a thyromental distance of 8 cm
  2. Mallampati class IV with a thyromental distance of 5 cm Correct answer.
  3. Neck circumference of 35 cm
  4. Body mass index of 24 kg/m²

Explanation

A Mallampati class IV oropharynx combined with a short thyromental distance (less than 6 cm) indicates reduced space for laryngoscopy and is a strong predictor of difficult direct laryngoscopy. Multiple abnormal predictors together are more predictive than any single one. Normal thyromental distance and low BMI are reassuring features.

Question 17General Anaesthesia and Airway Management

Which is the most appropriate initial management for laryngospasm persisting after removal of the stimulus in an anaesthetised patient?

  1. Immediate administration of suxamethonium 1 mg/kg
  2. 100% oxygen with continuous positive airway pressure and a jaw thrust Correct answer.
  3. Insertion of an oropharyngeal airway in a lightly anaesthetised patient
  4. Extubation and bag-mask ventilation

Explanation

Initial management of laryngospasm is removal of the stimulus, 100% oxygen with continuous positive airway pressure and a jaw thrust, which often breaks the spasm. If this fails, deepening anaesthesia with propofol or a small dose of suxamethonium is used. Inserting an oropharyngeal airway in a lightly anaesthetised patient can worsen laryngospasm.

Question 18General Anaesthesia and Airway Management

A patient with a large anterior mediastinal mass is scheduled for biopsy under general anaesthesia. Which induction strategy is safest?

  1. Supine rapid sequence induction with muscle relaxation
  2. Maintenance of spontaneous ventilation with the patient positioned to relieve compression Correct answer.
  3. Positive pressure ventilation in the supine position from the outset
  4. Deep anaesthesia with a volatile agent and muscle relaxation

Explanation

In anterior mediastinal masses, loss of spontaneous ventilation and muscle relaxation can cause airway or cardiovascular collapse from compression of the trachea or great vessels. Maintaining spontaneous ventilation and positioning the patient to relieve compression, such as sitting or lateral, is safest. Positive pressure ventilation in the supine position may worsen obstruction.

Question 19General Anaesthesia and Airway Management

Which statement about the use of a gum elastic bougie in difficult intubation is most accurate?

  1. It is contraindicated when the laryngeal view is Cormack-Lehane grade 3
  2. It should be used only after a failed supraglottic airway insertion
  3. It is passed blindly and must be confirmed by a click or hold-up before the tube is railroaded Correct answer.
  4. It should be inserted through the working channel of a fibrescope

Explanation

A gum elastic bougie is passed blindly beneath the epiglottis, and tracheal placement is confirmed by palpable clicks as it passes over tracheal rings or by hold-up in a small bronchus. The tube is then railroaded over it. It is useful precisely in grade 3 views and is not inserted through a fibrescope.

Question 20General Anaesthesia and Airway Management

Which preoxygenation technique achieves the highest end-tidal oxygen concentration in a healthy adult?

  1. Four vital capacity breaths over 30 seconds
  2. One deep breath followed by immediate induction
  3. Three minutes of tidal volume breathing with a tight-fitting mask Correct answer.
  4. Two minutes of tidal volume breathing with a nasal cannula at 4 L/min

Explanation

Three minutes of tidal volume breathing with a tight-fitting mask achieves end-tidal oxygen above 90% in most healthy adults. Four vital capacity breaths can achieve similar results in cooperative patients but are less reliable. Nasal cannula oxygen does not denitrogenate the lungs sufficiently for preoxygenation.

Question 21General Anaesthesia and Airway Management

A patient with a known difficult airway is being managed with a second-generation supraglottic airway. Which feature most distinguishes it from a first-generation device?

  1. A larger cuff volume
  2. A gastric drainage channel and a higher seal pressure Correct answer.
  3. A shorter insertion depth
  4. A softer tip for easier insertion

Explanation

Second-generation supraglottic airways add a gastric drainage channel and a better-designed cuff that achieves higher seal pressures, reducing aspiration risk and improving ventilation. Cuff volume, insertion depth and tip softness do not define the second-generation classification.

Question 22General Anaesthesia and Airway Management

Which physiological change during general anaesthesia most increases the risk of atelectasis in the dependent lung?

  1. Increase in functional residual capacity
  2. Increase in chest wall compliance
  3. Reduction in closing capacity
  4. Loss of hypoxic pulmonary vasoconstriction Correct answer.

Explanation

Anaesthesia reduces functional residual capacity below closing capacity, causing airway closure and atelectasis in dependent regions. Loss of hypoxic pulmonary vasoconstriction impairs the diversion of blood away from poorly ventilated areas, worsening shunt. Increased FRC and reduced closing capacity would be protective, not harmful.

Question 23General Anaesthesia and Airway Management

A patient requires emergency intubation for a head injury with a Glasgow Coma Scale of 6. Which induction agent is most appropriate to maintain cerebral perfusion pressure?

  1. Ketamine 1.5 mg/kg Correct answer.
  2. Thiopentone 5 mg/kg
  3. Propofol 2.5 mg/kg
  4. Sevoflurane 8% inhalational induction

Explanation

Ketamine preserves systemic vascular resistance and blood pressure, helping maintain cerebral perfusion pressure in a hypotensive head-injured patient. Propofol and thiopentone cause vasodilation and hypotension, which can critically reduce cerebral perfusion. Volatile induction is slow and also causes vasodilation.

Question 24General Anaesthesia and Airway Management

Which statement about the Mallampati classification is correct?

  1. It predicts difficult mask ventilation more reliably than difficult laryngoscopy
  2. It is assessed with the patient sitting, mouth fully open and tongue protruded without phonation
  3. Class I indicates the soft palate, fauces, uvula and tonsillar pillars are visible Correct answer.
  4. It is assessed with the patient supine and the tongue relaxed

Explanation

Mallampati class I describes visibility of the soft palate, fauces, uvula and tonsillar pillars. The assessment is performed with the patient sitting, mouth open and tongue protruded without phonation. It predicts difficult laryngoscopy rather than difficult mask ventilation.

Question 25General Anaesthesia and Airway Management

A patient with myasthenia gravis is undergoing general anaesthesia. Which neuromuscular management plan is most appropriate?

  1. Suxamethonium as the sole relaxant
  2. Reduced dose of non-depolarising blocker guided by quantitative neuromuscular monitoring Correct answer.
  3. Standard dose of rocuronium with no monitoring
  4. Avoidance of neuromuscular monitoring because the disease alters baseline responses

Explanation

Patients with myasthenia gravis are sensitive to non-depolarising neuromuscular blockers and require reduced doses titrated with quantitative monitoring. Suxamethonium may be used but is not the sole relaxant, and resistance can occur. Neuromuscular monitoring is essential to avoid residual blockade.

Question 26General Anaesthesia and Airway Management

During routine preoxygenation of a healthy adult before induction of general anaesthesia, which physiological principle best explains the increased safe apnoea time achieved with a tight-fitting facemask?

  1. Absorption atelectasis is actively reversed by the high inspired fraction
  2. Hypoventilation-induced hypercapnia stimulates residual oxygen uptake
  3. Haemoglobin oxygen saturation is raised well above its normal ceiling
  4. Denitrogenation of the functional residual capacity raises the alveolar oxygen reservoir Correct answer.

Explanation

Replacing alveolar nitrogen with oxygen enlarges the oxygen store within the functional residual capacity, so haemoglobin desaturates more slowly during apnoea. The benefit depends on a good mask seal and an adequate functional residual capacity, not on raising saturation beyond its physiological maximum.

Question 27General Anaesthesia and Airway Management

A patient is anaesthetised with a volatile agent and the vaporiser is set to deliver 2% sevoflurane. Which statement correctly describes the relationship between dialled concentration, alveolar concentration and brain partial pressure during uptake?

  1. Dialled concentration equals alveolar concentration from the first minute of administration
  2. Alveolar concentration rises more slowly than inspired concentration because of uptake into blood and tissue Correct answer.
  3. Brain partial pressure equilibrates with inspired concentration before it equilibrates with arterial blood
  4. Alveolar concentration exceeds inspired concentration until steady state is reached

Explanation

Uptake of anaesthetic into pulmonary blood and then into tissues removes agent from the alveoli, so the alveolar concentration lags behind the inspired concentration until equilibrium. Brain partial pressure tracks arterial partial pressure, which in turn follows alveolar partial pressure.

Question 28General Anaesthesia and Airway Management

A 70-year-old man with a body mass index of 42 kg/m2 is positioned supine for induction. Which combination of measures most effectively reduces his risk of rapid oxygen desaturation during apnoea?

  1. Deep sedation with a nasal cannula at 2 L/min for five minutes before induction
  2. Immediate supine intubation without preoxygenation to minimise apnoea duration
  3. Preoxygenation with a simple facemask at 6 L/min for two minutes
  4. Head-up ramped positioning with tight-mask preoxygenation to an end-tidal oxygen fraction above 0.9 Correct answer.

Explanation

Ramped head-up positioning improves functional residual capacity and mechanics in the obese patient, while high-flow tight-mask preoxygenation with end-tidal oxygen monitoring confirms adequate denitrogenation. Together these lengthen the safe apnoea interval and allow more time for airway manoeuvres.

Question 29General Anaesthesia and Airway Management

Which statement about the cuff of a tracheal tube placed in the trachea is most accurate?

  1. The cuff should be inflated until the pilot balloon feels firm, which reliably indicates a safe pressure
  2. Cuff pressure should routinely exceed 40 cmH2O to guarantee an airtight seal
  3. Nitrous oxide diffusion into the cuff reduces intracuff pressure over time
  4. A high-volume low-pressure cuff seals at a pressure below mucosal capillary perfusion pressure when correctly inflated Correct answer.

Explanation

A high-volume low-pressure cuff distributes force over a larger area, allowing a seal at pressures below the capillary perfusion pressure of the tracheal mucosa, usually targeted at 20 to 30 cmH2O. Cuff pressure should be measured with a manometer rather than estimated by palpation.

Question 30General Anaesthesia and Airway Management

During a general anaesthetic with mechanical ventilation, the capnogram suddenly loses its plateau and the end-tidal carbon dioxide falls sharply while the patient remains haemodynamically stable. Which cause should be considered first?

  1. A sudden rise in cardiac output
  2. A leak in the breathing circuit or a partially disconnected sampling line Correct answer.
  3. Hypoventilation from residual neuromuscular blockade
  4. A malignant hyperthermia crisis

Explanation

A lost plateau with a falling end-tidal value in a stable patient most often reflects a circuit leak, disconnection or sampling problem, because exhaled gas is diluted or lost. Hypoventilation and hypermetabolic states raise end-tidal carbon dioxide rather than lowering it.

Question 31General Anaesthesia and Airway Management

A patient with a history of asthma is undergoing general anaesthesia with a laryngeal mask airway. Which strategy best reduces the risk of bronchospasm during emergence?

  1. Hyperventilating the lungs to a low end-tidal carbon dioxide before removal
  2. Extubating during light anaesthesia to encourage an early cough
  3. Administering a beta-blocker before emergence
  4. Deepening anaesthesia before airway manipulation and ensuring adequate analgesia before extubation Correct answer.

Explanation

Airway reflexes are blunted when anaesthesia is deep enough and nociception is controlled, so manipulating or removing the device at an adequate depth reduces the stimulus for bronchospasm. Adequate analgesia prevents the sympathetic and vagal responses that provoke reflex bronchoconstriction.

Question 32General Anaesthesia and Airway Management

Which statement about the use of a nasopharyngeal airway in an obstructed but spontaneously breathing patient is correct?

  1. Its length should be estimated from the nostril to the thyroid cartilage
  2. It is contraindicated in patients with an intact gag reflex
  3. It should be avoided in a patient with a basal skull fracture because of the risk of intracranial placement Correct answer.
  4. It is preferred over an oropharyngeal airway in a patient with a fractured mandible

Explanation

Blind nasal insertion risks passing the device through a fractured cribriform plate into the cranial vault, so a suspected basal skull fracture is a contraindication. The device is otherwise useful in patients with preserved reflexes who may not tolerate an oropharyngeal airway.

Question 33General Anaesthesia and Airway Management

A patient is being ventilated through a tracheal tube and the peak airway pressure rises while the plateau pressure remains unchanged. Which interpretation is most accurate?

  1. The increase reflects a pneumothorax
  2. The increase reflects added resistance in the tube, circuit or large airways Correct answer.
  3. The increase reflects abdominal distension reducing thoracic compliance
  4. The increase reflects reduced lung compliance such as pulmonary oedema

Explanation

When plateau pressure is unchanged, alveolar distending pressure is unchanged, so the added pressure is consumed overcoming flow resistance in the tube, circuit or conducting airways. Causes include kinking, secretions, bronchospasm or a partially obstructed tube.

Question 34General Anaesthesia and Airway Management

Which statement about the second gas effect during inhalational induction is most accurate?

  1. Uptake of a large volume of nitrous oxide concentrates the remaining volatile agent in the alveoli and accelerates its rise in blood Correct answer.
  2. It results from the diffusion of volatile agent into the nitrous oxide cylinder
  3. It describes the accumulation of carbon dioxide when two gases are mixed
  4. It refers to the slowing of induction when two volatile agents are used together

Explanation

Rapid uptake of a high-concentration gas such as nitrous oxide shrinks the alveolar volume, so the partial pressure of any co-administered agent rises faster than it otherwise would. This concentrating effect modestly speeds induction and is termed the second gas effect.

Question 35General Anaesthesia and Airway Management

A patient with a known difficult airway is being ventilated with a supraglottic airway and the capnogram shows a normal square waveform with an adequate end-tidal value. Which conclusion is most defensible?

  1. The device is definitely positioned in the trachea
  2. Alveolar ventilation is occurring, but the seal and position should still be assessed before relying on the device Correct answer.
  3. No further monitoring of the airway is required for the rest of the case
  4. The device is definitely seated in the oesophagus

Explanation

A normal capnogram confirms that exhaled gas from the lungs is being sampled and that ventilation is occurring, but it does not by itself confirm optimal seating or seal. Oropharyngeal leak pressure and fibreoptic position should still be checked before depending on the device.

Question 36General Anaesthesia and Airway Management

Which statement about the physiology of laryngospasm is most accurate?

  1. It is abolished by deepening anaesthesia with a volatile agent
  2. It is caused by active contraction of the cricothyroid muscle opening the glottis
  3. It results from paralysis of the recurrent laryngeal nerve
  4. It is a reflex adduction of the vocal cords mediated by the superior laryngeal nerve after stimulation of the laryngeal mucosa Correct answer.

Explanation

Laryngospasm is a protective reflex in which sensory input from the superior laryngeal nerve triggers sustained adduction of the vocal cords. It is most common during light anaesthesia or emergence when the airway is stimulated.

Question 37General Anaesthesia and Airway Management

A patient with a predicted difficult mask ventilation and a predicted difficult intubation is being managed in theatre. Which plan best reflects current airway management principles?

  1. Using a supraglottic airway as the sole planned technique
  2. A pre-formulated strategy with awake or optimised induction, multiple backup devices and a declared surgical airway plan Correct answer.
  3. Proceeding directly to repeated direct laryngoscopy until intubation succeeds
  4. Relying on a single experienced operator without a backup plan

Explanation

When both mask ventilation and intubation are predicted to be difficult, a pre-declared plan with alternatives and an exit strategy is essential. The plan should include optimisation of the first attempt, a range of devices and a clear trigger for a surgical airway.

Question 38General Anaesthesia and Airway Management

Which statement about the use of a neuromuscular blocking agent in a patient with a history of suxamethonium-induced hyperkalaemia is correct?

  1. Suxamethonium is safe if given after a defasciculating dose of a non-depolarising agent
  2. Suxamethonium is safe if a small dose is given
  3. Suxamethonium is safe if the serum potassium is normal at the time of induction
  4. Suxamethonium should be avoided because of the risk of further life-threatening hyperkalaemia, and a non-depolarising agent should be used Correct answer.

Explanation

Prior suxamethonium-induced hyperkalaemia indicates upregulation of extrajunctional receptors, so repeat exposure can cause a severe and potentially fatal potassium rise. A non-depolarising agent is used instead, with appropriate monitoring.

Question 39General Anaesthesia and Airway Management

Which statement about the use of cricoid pressure during rapid sequence induction is most accurate?

  1. It should be maintained at full force even if it obstructs the view at laryngoscopy
  2. It abolishes the need for a clear suction plan
  3. It is applied to reduce the risk of passive regurgitation and should be adjusted or released if it impedes ventilation or intubation Correct answer.
  4. It is applied to the thyroid cartilage to compress the oesophagus

Explanation

Cricoid pressure compresses the oesophagus against the vertebral body to reduce passive regurgitation during induction. If it impairs ventilation or the laryngeal view it should be reduced or released, since a failed airway is a greater immediate threat.

Question 40General Anaesthesia and Airway Management

Which statement best describes the physiological basis of positive end-expiratory pressure in improving oxygenation during general anaesthesia?

  1. It directly increases the inspired oxygen fraction
  2. It recruits collapsed alveoli and keeps them open at end-expiration, reducing intrapulmonary shunt Correct answer.
  3. It decreases functional residual capacity
  4. It increases cardiac output and therefore oxygen delivery

Explanation

Positive end-expiratory pressure maintains alveolar patency and recruits collapsed units, reducing the proportion of perfused but unventilated lung, that is, shunt. The benefit must be balanced against its effects on venous return and cardiac output.

Question 41Regional Anaesthesia and Pain Medicine

A 28-year-old primigravida at 39 weeks requests labour epidural analgesia. After a 3 mL test dose of 1.5% lidocaine with 1:200,000 adrenaline, she reports perioral tingling and tinnitus, and within 60 seconds becomes unresponsive with a generalised tonic-clonic seizure. Which is the most appropriate immediate step?

  1. Administer 20% lipid emulsion 1.5 mL/kg as a bolus while continuing airway management with 100% oxygen Correct answer.
  2. Give intravenous magnesium sulphate 4 g over 10 minutes
  3. Give intravenous adrenaline 1 mg as a bolus immediately
  4. Perform immediate caesarean delivery under general anaesthesia before treating the seizure

Explanation

This is local anaesthetic systemic toxicity (LAST) with convulsion. Standard management is to stop injection, secure the airway with 100% oxygen, control seizures (benzodiazepines), and give intravenous 20% lipid emulsion as a bolus of approximately 1.5 mL/kg followed by an infusion. Lipid emulsion is the specific antidote and should not be delayed for airway manoeuvres alone.

Question 42Regional Anaesthesia and Pain Medicine

Which nerve block provides reliable surgical anaesthesia of the entire anterior and posterior aspects of the knee capsule when performed as a single-injection technique?

  1. Femoral nerve block
  2. Adductor canal block
  3. Combined femoral and sciatic nerve block Correct answer.
  4. Sciatic nerve block at the popliteal fossa

Explanation

The knee receives innervation from both the femoral nerve (anterior and medial) and the sciatic nerve (posterior). A single femoral or adductor canal block leaves the posterior capsule unanaesthetised, so complete surgical anaesthesia requires blockade of both territories.

Question 43Regional Anaesthesia and Pain Medicine

When performing a spinal anaesthetic for caesarean section, which physiological change most commonly causes maternal hypotension?

  1. Increased vagal tone from the block
  2. Sympathetic blockade causing arterial and venous dilatation Correct answer.
  3. Direct myocardial depression from the local anaesthetic
  4. Aortocaval compression alone

Explanation

Spinal anaesthesia blocks sympathetic fibres, producing arteriolar dilatation and venous pooling with reduced preload and cardiac output. This sympatholysis is the dominant cause of hypotension; aortocaval compression contributes but is not the primary mechanism.

Question 44Regional Anaesthesia and Pain Medicine

A patient with severe aortic stenosis is scheduled for hip surgery. Which neuraxial technique is most likely to cause dangerous haemodynamic compromise?

  1. Single-shot spinal anaesthesia Correct answer.
  2. Continuous spinal catheter with titrated dosing
  3. Lumbar epidural with incremental dosing
  4. Combined spinal-epidural with low-dose spinal

Explanation

In severe aortic stenosis, fixed cardiac output means hypotension from sympathetic blockade cannot be compensated by increased stroke volume. A single-shot spinal produces abrupt, non-titratable sympathectomy and is therefore the highest risk. Incremental or catheter-based techniques allow gradual titration.

Question 45Regional Anaesthesia and Pain Medicine

Which structure must be identified and avoided during a supraclavicular brachial plexus block to reduce the risk of pneumothorax?

  1. The subclavian artery
  2. The external jugular vein
  3. The phrenic nerve
  4. The pleura overlying the first rib Correct answer.

Explanation

The supraclavicular approach places the needle close to the dome of the pleura over the first rib, so pneumothorax is the characteristic complication. Ultrasound guidance with a lateral-to-medial in-plane trajectory and shallow needle depth reduces this risk.

Question 46Regional Anaesthesia and Pain Medicine

A 70-year-old man on warfarin for atrial fibrillation has an INR of 3.2 and needs an urgent femoral nerve block for analgesia after hip fracture. Which is the most appropriate action?

  1. Perform the block via the adductor canal instead because it is a lower-risk site
  2. Correct the coagulopathy before considering the block and use systemic analgesia meanwhile Correct answer.
  3. Proceed with the block using ultrasound guidance because the femoral nerve is superficial
  4. Proceed with the block after giving fresh frozen plasma

Explanation

An INR of 3.2 exceeds the accepted threshold for deep peripheral nerve blocks, and femoral block is a deep, non-compressible-site procedure. The coagulopathy should be corrected or the block deferred, with multimodal systemic analgesia used in the interim.

Question 47Regional Anaesthesia and Pain Medicine

Which analgesic strategy is recommended as part of a multimodal regimen after major surgery to reduce opioid consumption?

  1. Scheduled paracetamol combined with a non-steroidal anti-inflammatory drug where not contraindicated Correct answer.
  2. A single preoperative dose of opioid only
  3. Regular intramuscular pethidine four times daily
  4. Opioid monotherapy titrated to pain score

Explanation

Multimodal analgesia combining paracetamol with an NSAID (when renal, gastrointestinal and cardiovascular risk allow) provides additive analgesia and reduces opioid requirements. Opioid-sparing regimens are central to enhanced recovery pathways.

Question 48Regional Anaesthesia and Pain Medicine

During a posterior approach to the lumbar plexus (psoas compartment block), which complication is most characteristic?

  1. Recurrent laryngeal nerve injury
  2. Phrenic nerve palsy
  3. Horner syndrome
  4. Epidural spread of local anaesthetic Correct answer.

Explanation

The psoas compartment block carries a recognised risk of epidural spread because the psoas muscle sheath communicates with the epidural space. Bilateral or extensive spread can cause high neuraxial block and hypotension.

Question 49Regional Anaesthesia and Pain Medicine

Which finding on ultrasound most reliably confirms correct needle placement for an interscalene brachial plexus block?

  1. Needle tip between the anterior and middle scalene muscles adjacent to the plexus roots Correct answer.
  2. Needle tip superficial to the sternocleidomastoid muscle
  3. Needle tip deep to the prevertebral fascia medial to the carotid artery
  4. Needle tip within the subclavian artery sheath

Explanation

The interscalene plexus lies in the interscalene groove between the anterior and middle scalene muscles, appearing as hypoechoic nodules (the traffic-light sign). Correct placement is between these muscles, superficial to the prevertebral fascia.

Question 50Regional Anaesthesia and Pain Medicine

A patient develops a high sensory block to C5 with hypotension and difficulty breathing 10 minutes after a spinal anaesthetic. Which is the most likely explanation?

  1. Anaphylaxis to the local anaesthetic
  2. A pneumothorax from the spinal needle
  3. Total spinal anaesthesia from excessive cephalad spread Correct answer.
  4. Local anaesthetic systemic toxicity

Explanation

Cephalad spread of local anaesthetic to the cervical dermatomes, with hypotension and respiratory compromise, indicates a total spinal. Management includes airway support, vasopressors and fluids, and often intubation until the block recedes.