FMGE 2025 — Anesthesiology
16 Previous Year Questions with Answers & Explanations
A 35 y/o asthmatic patient is scheduled for a minor surgical procedure. Which induction agent and muscle relaxant combination is safest for this patient?
A patient undergoing surgery is administered succinylcholine for muscle relaxation. Shortly after administration, he develops hyperthermia, muscle rigidity, tremors, and tachycardia. What is the most appropriate treatment for this condition?
A patient scheduled for elective hip surgery is currently taking aspirin, enalapril, a multivitamin, and metoprolol. The surgery is planned in 5 days. What is the appropriate perioperative management for this patient?
A patient undergoing general anesthesia develops left lung collapse following intubation. On auscultation, breath sounds are heard only on the right side. What is the most likely cause of this condition?
According to the American Heart Association (AHA), what is the 6th link added to the chain of survival?
An RTA patient has received 4 units of packed RBCs within a few hours. Which of the following will be seen?
A known case of hyperthyroidism, who is not on medication, is scheduled for total thyroidectomy. The PAC check was not done properly. What is the leading complication that can occur during surgery?
A patient is in ICU and there is a failed attempt of subclavian catheterization. Shortly after, BP drops and the pulse rises. What is the diagnosis?
Which is the best confirmatory method to ensure the central line is in the jugular vein?
In the image shown, identify the function of the marked structure on the endotracheal tube.
FMGE 2025 - Anesthesiology FMGE Practice Questions and MCQs
Question 1: A 35 y/o asthmatic patient is scheduled for a minor surgical procedure. Which induction agent and muscle relaxant combination is safest for this patient?
- A. Ketamine and Vecuronium (Correct Answer)
- B. Propofol and Succinylcholine
- C. Ketamine and d-tubocurarine
- D. Thiopental and Rocuronium
Explanation: ***Ketamine and Vecuronium***- **Ketamine** is strongly recommended for asthmatics as it possesses potent **bronchodilating properties** via its sympathomimetic effects, helping prevent **bronchospasm**.- **Vecuronium** is an intermediate-acting non-depolarizing muscle relaxant that causes **minimal to no histamine release**, ensuring cardiovascular stability and avoiding airway irritation.*Propofol and Succinylcholine*- While **Propofol** is often used and generally considered safe (neutral to mild bronchodilation), **Succinylcholine**, a depolarizing agent, carries a potential risk of **histamine release**, although low.- The combination is generally acceptable but less preferred than Ketamine based on the strength of Ketamine's **bronchodilating effect**.*Ketamine and d-tubocurarine*- **Ketamine** is beneficial due to its **bronchodilating effect**, but **d-tubocurarine (DTC)** is highly associated with massive **histamine release**.- DTC often causes severe **hypotension** and significant **bronchospasm**, making it extremely unsafe for an asthmatic patient.*Thiopental and Rocuronium*- **Thiopental**, a barbiturate, is associated with a risk of **histamine release** and potential exacerbation of asthma symptoms or cough upon induction.- Although **Rocuronium** is a safe, low-histamine muscle relaxant, the use of **Thiopental** makes this combination less safe than using Ketamine.
Question 2: A patient undergoing surgery is administered succinylcholine for muscle relaxation. Shortly after administration, he develops hyperthermia, muscle rigidity, tremors, and tachycardia. What is the most appropriate treatment for this condition?
- A. Neostigmine
- B. Midazolam
- C. Dantrolene sodium (Correct Answer)
- D. Atropine
Explanation: ***Dantrolene sodium***- This is the specific and definitive antidote for **Malignant Hyperthermia (MH)**, characterized by signs like hyperthermia, muscle rigidity, and tachycardia after succinylcholine administration.- **Dantrolene** works directly on skeletal muscle by inhibiting the release of calcium from the **sarcoplasmic reticulum**, thereby interrupting the sustained muscle contraction and hypermetabolic state.*Neostigmine*- It is an **acetylcholinesterase inhibitor** used to reverse the effects of non-depolarizing neuromuscular blocking agents (e.g., rocuronium).- It is **contraindicated** in MH as it could potentially exacerbate muscle rigidity and the hypermetabolic crisis by increasing **acetylcholine** activity at the neuromuscular junction.*Atropine*- This is an **anticholinergic** drug primarily used to treat bradycardia or to dry secretions.- Although the patient exhibits severe tachycardia, atropine does not treat the underlying pathological hypermetabolism or the excessive calcium release that defines MH.*Midazolam*- This is a **benzodiazepine** used for anxiolysis, sedation, and if necessary, managing seizures.- While supportive care for MH might involve benzodiazepines if seizures occur due to hyperthermia, it is not the crucial drug needed to counteract the life-threatening hypermetabolic crisis.
Question 3: A patient scheduled for elective hip surgery is currently taking aspirin, enalapril, a multivitamin, and metoprolol. The surgery is planned in 5 days. What is the appropriate perioperative management for this patient?
- A. Stop enalapril (Correct Answer)
- B. Stop aspirin to minimize perioperative bleeding risk
- C. Stop metoprolol to increase cardiac output
- D. Increase aspirin dosage for additional analgesic benefit
Explanation: ***Correct: Stop enalapril*** - **ACE inhibitors (enalapril) should be discontinued 24-48 hours before elective surgery** - Risk of **refractory intraoperative hypotension** during anesthesia induction, particularly with vasodilatory anesthetics - Associated with increased perioperative complications including hypotension requiring vasopressor support - Can be safely restarted postoperatively once hemodynamic stability is achieved *Incorrect: Stop aspirin to minimize perioperative bleeding risk* - **Aspirin should generally be continued** in patients with cardiovascular indications (CAD, stroke prevention) - Current guidelines recommend continuation for most surgeries except those with very high bleeding risk (neurosurgery, posterior chamber eye surgery) - **Hip surgery is NOT a contraindication** to aspirin continuation - The cardiovascular risk of stopping aspirin outweighs bleeding risk in most cases *Incorrect: Stop metoprolol to increase cardiac output* - **Beta-blockers should be continued perioperatively** in patients already taking them - Abrupt withdrawal increases risk of **rebound hypertension, tachycardia, myocardial ischemia, and MI** - Stopping beta-blockers can precipitate life-threatening cardiovascular events - Should be given on the morning of surgery with a sip of water *Incorrect: Increase aspirin dosage for additional analgesic benefit* - No indication to increase aspirin dose perioperatively - Aspirin is not used as a primary analgesic in surgical settings - Increasing dose would unnecessarily increase bleeding risk without therapeutic benefit
Question 4: A patient undergoing general anesthesia develops left lung collapse following intubation. On auscultation, breath sounds are heard only on the right side. What is the most likely cause of this condition?
- A. Pneumothorax on the left side due to positive pressure ventilation
- B. Bronchospasm
- C. Right endobronchial intubation (Correct Answer)
- D. Mucus secretions obstructing the endotracheal tube
Explanation: ***Right endobronchial intubation***- This is the most common cause of unilateral lung collapse *immediately* following intubation, as the endotracheal tube (ETT) is usually advanced too far into the **right main bronchus (RMB)**, which is wider and less acutely angled than the left.- When the ETT is solely in the RMB, air ventilates the right lung exclusively, resulting in **absent breath sounds** and subsequent **atelectasis** (collapse) of the non-ventilated left lung.*Mucus secretions obstructing the endotracheal tube*- Significant obstruction of the ETT by mucus would typically lead to **bilateral loss of breath sounds** or severely impaired ventilation (high peak inspiratory pressures), affecting both lungs equally.- The specific finding of unilateral breath sounds (only on the right) excludes a primary blockage of the ETT itself.*Pneumothorax on the left side due to positive pressure ventilation*- While a left **pneumothorax** can cause absent breath sounds on the left, it would involve air accumulation in the pleural space, often requiring significant barotrauma, and is a less frequent and less immediate cause than mainstem intubation following successful intubation.- The clinical picture of immediate unilateral absence of breath sounds following intubation is overwhelmingly attributed to ETT malposition, which causes obstructive **atelectasis** (collapse), not tension pneumothorax.*Bronchospasm*- **Bronchospasm** is characterized by diffuse airway narrowing, typically presenting with high **peak inspiratory pressures** and **wheezing** heard over both lung fields.- It impairs air entry bilaterally and would not result in the complete unilateral absence of breath sounds and lung collapse described, which is indicative of complete airway obstruction to the non-ventilated lung.
Question 5: According to the American Heart Association (AHA), what is the 6th link added to the chain of survival?
- A. Recovery and rehabilitation (Correct Answer)
- B. Advanced airway management
- C. High-quality CPR
- D. Rapid defibrillation
Explanation: ***Recovery and rehabilitation*** - The American Heart Association (**AHA**) added this as the **6th link** to the chain of survival to emphasize the importance of post-event care for cardiac arrest survivors. - This link focuses on the long-term health outcomes, addressing physical, cognitive, and emotional needs to improve the survivor's **quality of life**. *Rapid defibrillation* - This is the **fourth link** in the chain of survival, often grouped with Advanced Life Support (ALS). - It is a critical intervention for shockable rhythms like **ventricular fibrillation (VF)** and **pulseless ventricular tachycardia (VT)**, but it precedes post-cardiac arrest care and recovery. *High-quality CPR* - This is the **third link** in the chain of survival, immediately following activation of the emergency response system. - Its purpose is to maintain vital organ perfusion until defibrillation or the return of spontaneous circulation is achieved. *Advanced airway management* - This is a component of **Advanced Life Support (ALS)**, which is part of the fourth link in the chain. - While crucial during the resuscitation effort, it is an acute intervention and not the distinct final step focused on long-term patient recovery.
Question 6: An RTA patient has received 4 units of packed RBCs within a few hours. Which of the following will be seen?
- A. Hyperkalemia
- B. Hypocalcemia (Correct Answer)
- C. Hypernatremia
- D. Hyponatremia
Explanation: ***Hypocalcemia***- The anticoagulant used in packed RBCs, **citrate**, chelates (binds strongly to) **ionized calcium** in the recipient's plasma. - Rapid infusion during massive transfusion overwhelms the liver's capacity to metabolize citrate, causing a rapid decrease in **serum calcium** levels, potentially leading to immediate complications like paresthesias or prolonged QT interval.*Hypernatremia*- Packed RBCs are suspended in solutions that are typically isotonic or slightly hypotonic in sodium, making **Hypernatremia** an unlikely direct complication of transfusion.- Resuscitation fluids (like Normal Saline) used alongside transfused blood are the more common cause of slight hypernatremia in trauma patients, not the blood components themselves.*Hyponatremia*- Although some older blood preservatives might contain less sodium, **Hyponatremia** is not a primary biochemical disturbance associated with massive blood product transfusion.- Dilutional effects or the use of specific hypotonic fluids would be required to induce significant **Hyponatremia**, which is rare with standard trauma protocols.*Hyperkalemia*- Stored RBCs leak **potassium** (K+) into the supernatant fluid during storage, making hyperkalemia a risk, especially with older units or in patients with impaired renal function.- However, **Hypocalcemia** due to immediate **citrate toxicity** is generally considered the most frequent and immediate metabolic derangement requiring intervention during massive transfusion.
Question 7: A known case of hyperthyroidism, who is not on medication, is scheduled for total thyroidectomy. The PAC check was not done properly. What is the leading complication that can occur during surgery?
- A. Hypothyroidism
- B. Hypothermia
- C. Hyperthermia
- D. Arrhythmia (Correct Answer)
Explanation: ***Arrhythmia***- Uncontrolled **hyperthyroidism** significantly increases sympathetic cardiovascular stimulation, making the heart susceptible to **tachycardia** and cardiac instability during stress.- Intraoperative stress (from anesthesia and surgery) can trigger a **thyroid storm**, where the resulting severe ventricular tachycardia or **atrial fibrillation** poses the greatest immediate threat to life during the procedure.*Hyperthermia*- Although **hyperthermia** (high fever) is a critical classic sign of a **thyroid storm**, immediate cardiovascular collapse due to **arrhythmias** typically precedes or dominates the intraoperative crisis.- The underlying increase in the **basal metabolic rate (BMR)** in hyperthyroidism predisposes the patient to thermal dysregulation, which is exacerbated during surgery.*Hypothermia*- **Hypothermia** (low body temperature) is extremely unlikely as the leading complication in an actively hyperthyroid patient due to their persistently elevated **BMR**.- This complication would be more typical of severe non-thyroid disease or prolonged surgery with poor thermal management, not directly caused by unmedicated hyperthyroidism itself.*Hypothyroidism*- **Hypothyroidism** is a predictable *long-term complication* following a successful **total thyroidectomy** and subsequent removal of functional thyroid tissue.- This condition is not an acute, intraoperative complication resulting from the lack of proper preoperative control of the underlying **thyrotoxicosis**.
Question 8: A patient is in ICU and there is a failed attempt of subclavian catheterization. Shortly after, BP drops and the pulse rises. What is the diagnosis?
- A. Air embolism
- B. Displacement of endotracheal tube (ET)
- C. Pneumothorax (Correct Answer)
- D. Hemothorax
Explanation: ***Pneumothorax*** - A failed attempt at **subclavian vein catheterization** carries a high risk of puncturing the **parietal pleura** (due to the proximity of the apex of the lung), leading to a pneumothorax. - The sudden drop in **blood pressure (hypotension)** and rise in **pulse (tachycardia)** indicate acute hemodynamic compromise, often resulting from a **tension pneumothorax** which impedes venous return to the heart. - This is the **most common mechanical complication** of subclavian catheterization. *Displacement of endotracheal tube (ET)* - Displacement means the tube moves from the correct **tracheal position** (e.g., into the esophagus or mainstem bronchus), leading to acute ventilation failure and hypoxia. - While displacement causes hemodynamic instability, it is a complication of **ventilator management or patient movement**, not directly related to a preceding failed attempt at a **central venous line insertion**. *Air embolism* - An air embolism occurs when air enters the venous circulation, usually when the central line tract or needle hub is open to the atmosphere (e.g., during line insertion or removal) and the patient takes a deep breath. - Although it can cause cardiovascular collapse, the presenting feature following a needle stick is classically **pneumothorax**, unless the catheter was successfully placed and air was entrained through the line. - Classic sign: **mill-wheel murmur** on auscultation. *Hemothorax* - Hemothorax results from **vascular injury** (subclavian artery or vein) during catheterization attempts, causing blood accumulation in the pleural space. - While it can occur with subclavian catheterization, it typically presents with **more gradual hemodynamic changes** and signs of blood loss (falling hematocrit), rather than the acute decompensation seen with tension pneumothorax. - Chest X-ray would show pleural fluid rather than air.
Question 9: Which is the best confirmatory method to ensure the central line is in the jugular vein?
- A. ETCO2
- B. Blood color
- C. Chest x-ray (Correct Answer)
- D. Blood pH
Explanation: ***Chest x-ray (Correct)*** - This is the **gold standard confirmatory method** to verify central venous catheter tip position, ensuring it rests appropriately in the **superior vena cava (SVC)** or at the cavoatrial junction - Post-procedure CXR is essential to screen for **mechanical complications** such as **pneumothorax** or hemothorax, which is paramount for patient safety - Provides anatomical confirmation of proper catheter placement *Blood pH (Incorrect)* - While blood gas analysis can differentiate an **arterial sample** from a venous sample (if accidental arterial puncture occurs), it does **not confirm the anatomical location** of the catheter tip within the venous system - Blood pH is a chemical test for systemic acid-base status, not an imaging technique for assessing catheter placement - Cannot verify the catheter tip is in the appropriate position (SVC/cavoatrial junction) *Blood color (Incorrect)* - Visual inspection of blood color (bright red for arterial, dark red for venous) is **unreliable and subjective** - Especially inaccurate in patients who are hypotensive, septic, or significantly hypoxic, as these conditions can darken arterial blood - Provides **no information** about the final resting location of the catheter tip, which is critical to avoid complications like cardiac perforation or malposition *ETCO2 (Incorrect)* - **End-tidal carbon dioxide (ETCO2)** measurement is used to monitor ventilatory status and efficiency of gas exchange - Primarily used for confirming **tracheal intubation** in airway management - This measurement is **completely unrelated** to the physical placement or confirmation of a central venous catheter
Question 10: In the image shown, identify the function of the marked structure on the endotracheal tube.
- A. Prevention of air leakage and aspiration (Correct Answer)
- B. Suctioning of lower respiratory tract secretions
- C. Monitoring airway pressure
- D. Facilitation of vocal cord visualization
Explanation: ***Prevention of air leakage and aspiration*** - The marked structure is the **inflatable cuff** of the endotracheal tube, which, when inflated, creates a seal against the wall of the trachea. - This seal ensures that air delivered during **positive pressure ventilation** goes directly to the lungs without leaking and also prevents **aspiration** of gastric or pharyngeal contents into the lower airway. *Facilitation of vocal cord visualization* - Visualization of the vocal cords is accomplished using a **laryngoscope** during the process of intubation, before the cuff is inflated. - The cuff is located distal to the tip and is inflated only after the tube has been correctly positioned past the vocal cords. *Monitoring airway pressure* - Overall airway pressure (like peak inspiratory pressure) is monitored through the **ventilator circuit**, not by the cuff itself. - The **pilot balloon**, connected to the cuff, allows for monitoring of the **cuff pressure** to avoid tracheal injury, but it does not measure airway breathing pressure. *Suctioning of lower respiratory tract secretions* - Suctioning of secretions from the lower respiratory tract is performed by passing a **suction catheter** through the main lumen of the endotracheal tube. - The cuff's role is to prevent aspiration, not to actively remove secretions, although specialized tubes may have a separate **subglottic suction port** located above the cuff.