HKCA Fellowship Final Examination - MCQ (Hong Kong)

During one-lung ventilation (OLV) for a thoracotomy, the patient's oxygen saturation (SpO2) falls to 88% despite ventilation with 100% oxygen. Which of the following is the most appropriate next step in management?

• AApply continuous positive airway pressure (CPAP) of 5 cm H2O to the non-dependent lung.
• BApply positive end-expiratory pressure (PEEP) of 10 cm H2O to the dependent lung.
• CImmediately clamp the pulmonary artery of the non-ventilated lung.
• DIncrease the tidal volume of the dependent lung to 10 mL/kg.

A patient undergoing cesarean delivery under spinal anesthesia experiences severe postpartum hemorrhage due to uterine atony. She has a history of mild pre-eclampsia. Which of the following uterotonic agents is relatively contraindicated in this patient?

• AOxytocin
• BErgometrine
• CCarboprost (Hemabate)
• DMisoprostol

A 3-year-old child develops severe laryngospasm with complete airway obstruction during emergence from general anesthesia. Despite application of 100% oxygen with continuous positive airway pressure (CPAP) and Larson's maneuver, the obstruction persists and bradycardia develops. Which of the following is the most appropriate next step?

• AAdminister intravenous atropine 20 mcg/kg.
• BAdminister intravenous succinylcholine 1-2 mg/kg.
• CPerform emergency surgical cricothyrotomy.
• DAdminister intravenous propofol 0.5 mg/kg.

A 75-year-old patient with severe asymptomatic aortic stenosis (valve area 0.7 cm², mean gradient 45 mmHg) requires urgent hip fracture surgery. Which of the following hemodynamic strategies is most appropriate during anesthesia?

• AMaintain systemic vascular resistance (SVR) and keep the heart rate between 50-70 bpm.
• BTarget a mild tachycardia (heart rate 90-100 bpm) to maintain cardiac output.
• CAdminister aggressive fluid boluses to maintain high preload.
• DReduce afterload (SVR) by 20-30% using an esmolol infusion.

A patient with a traumatic brain injury is undergoing an emergency craniotomy. The surgeon requests hyperventilation to reduce brain swelling. What is the mechanism of this effect, and what is the recommended lower limit of PaCO2 to avoid cerebral ischemia?

• AHyperventilation causes hypocapnia, leading to cerebral vasodilation; lower limit of PaCO…
• BHyperventilation causes hypocapnia, leading to cerebral vasoconstriction; lower limit of…
• CHyperventilation causes hypercapnia, leading to cerebral vasoconstriction; lower limit of…
• DHyperventilation increases intrathoracic pressure, improving venous drainage; lower limit…

A patient develops signs of Local Anaesthetic Systemic Toxicity (LAST) with cardiac arrest shortly after an ultrasound-guided interscalene brachial plexus block with 0.5% ropivacaine. According to the ASRA guidelines, which of the following is the correct dosing for lipid emulsion therapy?

• A20% Lipid emulsion: 1.5 mL/kg IV bolus over 1 minute, followed by an infusion of 0.25 mL/…
• B10% Lipid emulsion: 1.5 mL/kg IV bolus over 1 minute, followed by an infusion of 0.5 mL/k…
• C20% Lipid emulsion: 0.25 mL/kg IV bolus over 5 minutes, followed by an infusion of 1.5 mL…
• D20% Lipid emulsion: 5 mL/kg IV bolus, followed by an infusion of 1 mL/kg/min.

A postpartum patient who suffered an accidental dural puncture with a 16-gauge Tuohy needle during a labor epidural insertion presents with a severe, debilitating post-dural puncture headache (PDPH). Conservative management has failed. Which of the following is correct regarding an autologous epidural blood patch (EBP)?

• AThe patch is most effective if performed within the first 24 hours of the puncture.
• BThe patch should be performed after 24 hours of the puncture, injecting 15-20 mL of autol…
• CThe patch should be performed with a target volume of 50 mL of autologous blood.
• DAutologous blood must be mixed with heparin to prevent early epidural clot formation.

During a general anesthetic with sevoflurane and succinylcholine, a patient develops unexplained tachycardia, tachypnea, masseter spasm, and a rapid rise in end-tidal carbon dioxide (EtCO2) to 85 mmHg. Malignant hyperthermia (MH) is suspected. Which of the following is the most urgent pharmacological treatment?

• AAdminister intravenous dantrolene 2.5 mg/kg.
• BAdminister intravenous calcium chloride 1 g to stabilize the cardiac membrane.
• CAdminister intravenous sodium bicarbonate 100 mEq to treat acidosis.
• DInfuse cold saline at 40 mL/kg.

A 22-year-old male with a large anterior mediastinal mass is scheduled for a diagnostic biopsy. He reports dyspnea when lying flat. What is the safest anaesthetic plan for this patient?

• AInhalation induction with sevoflurane in the supine position.
• BRapid sequence induction with propofol and rocuronium in the supine position.
• CAwake fiberoptic intubation followed by mechanical ventilation.
• DMaintenance of spontaneous ventilation, preferably under local anesthesia or ketamine/dex…

Which of the following statements correctly distinguishes postoperative delirium (POD) from postoperative cognitive dysfunction (POCD)?

• APOD is characterized by an acute, fluctuating change in mental status, whereas POCD is a…
• BPOD is diagnosed using neuropsychological testing, while POCD is diagnosed clinically usi…
• CPOD occurs weeks to months after surgery, while POCD occurs in the immediate recovery per…
• DPOD is solely caused by anesthetic agents, whereas POCD is caused by patient age and como…

A 4-week-old infant is scheduled for pyloromyotomy for hypertrophic pyloric stenosis. The infant has been vomiting for 5 days. Which of the following is the most appropriate perioperative management?

• APerform urgent surgery as this is a surgical emergency; resuscitate intraoperatively.
• BDelay surgery to correct the hypochloremic hypokalemic metabolic alkalosis with 0.9% sali…
• CRapidly correct the fluid deficit using 5% dextrose in water (D5W) to prevent hypoglycemi…
• DMaintain a normal pH (7.40) using sodium bicarbonate before induction.

A 68-year-old male with a history of stable angina, type 2 diabetes mellitus on insulin, and a serum creatinine of 180 umol/L is scheduled for elective major colon resection. According to the Revised Cardiac Risk Index (RCRI), how many risk factors does this patient possess, and what is his risk classification?

• A2 risk factors; moderate risk.
• B3 risk factors; high risk.
• C4 risk factors; high risk.
• D1 risk factor; low risk.

A patient with myasthenia gravis is scheduled for a thymectomy. Which of the following is correct regarding the patient's response to neuromuscular blocking agents (NMBAs)?

• ASensitive to succinylcholine and resistant to rocuronium.
• BResistant to succinylcholine and sensitive to rocuronium.
• CResistant to both succinylcholine and rocuronium.
• DSensitive to both succinylcholine and rocuronium.

A pre-eclamptic patient receiving a magnesium sulfate infusion for seizure prophylaxis becomes lethargic and develops loss of patellar reflexes. Her respiratory rate is 8 breaths per minute. Which of the following is the most appropriate immediate treatment?

• AIncrease the rate of the magnesium sulfate infusion.
• BStop the magnesium infusion and administer 10 mL of 10% calcium gluconate intravenously.
• CAdminister intravenous naloxone 0.4 mg.
• DPerform emergency endotracheal intubation immediately.

A patient with severe mitral stenosis (mitral valve area 1.0 cm²) is scheduled for elective non-cardiac surgery under general anesthesia. Which of the following represents the primary hemodynamic goal?

• AMaintain a slow heart rate and sinus rhythm, avoiding tachycardia.
• BMaintain a high heart rate to preserve cardiac output.
• CEncourage vasodilation to reduce left ventricular afterload.
• DAllow moderate-to-severe volume expansion to maximize left ventricular filling.

A patient develops acute hypoxemia, bilateral pulmonary infiltrates, and fever 3 hours after receiving two units of packed red blood cells. The central venous pressure is low, and the brain natriuretic peptide (BNP) level is normal. Which of the following is the most likely diagnosis?

• ATransfusion-Associated Circulatory Overload (TACO)
• BTransfusion-Related Acute Lung Injury (TRALI)
• CHemolytic transfusion reaction
• DAnaphylactic transfusion reaction

During induction of general anesthesia, a patient develops severe bronchospasm, facial edema, and profound hypotension (BP 60/30 mmHg) after administration of atracurium. Anaphylaxis is suspected. In addition to high-flow oxygen and stopping triggers, what is the first-line drug therapy, and what is the optimal timing for drawing a blood sample for mast cell tryptase?

• AIntravenous hydrocortisone 200 mg; sample within 24 hours.
• BIntravenous adrenaline (epinephrine) 10-50 mcg boluses (for Grade 3); sample at 1-2 hours…
• CIntravenous chlorpheniramine 10 mg; sample immediately.
• DIntravenous glucagon 1 mg; sample at 6 hours.

During a neonatal resuscitation at birth, the newborn is apneic and has a heart rate of 50 bpm despite 30 seconds of effective positive pressure ventilation (PPV). What is the next step in resuscitation?

• AIncrease the PPV rate to 80 breaths per minute.
• BStart chest compressions at a 3:1 ratio with ventilation, using 100% oxygen.
• CAdminister intravenous adrenaline 0.1 mg/kg.
• DStop PPV and perform tactile stimulation.

A patient with an implantable cardioverter-defibrillator (ICD) and pacemaker is scheduled for a hemicolectomy using monopolar electrocautery. Which of the following perioperative management steps is most appropriate?

• ADo nothing as modern ICDs are immune to electromagnetic interference (EMI).
• BProgram the ICD to disable tachycardia detection/therapy (anti-tachycardia pacing and sho…
• CPlace a magnet over the device to permanently change the ICD to an asynchronous pacing mo…
• DApply the electrocautery return pad as close to the ICD generator as possible.

A patient has been paralyzed with rocuronium for a short procedure. At the end of the surgery, the train-of-four (TOF) monitor shows 0 responses, but the post-tetanic count (PTC) is 2. Which dose of sugammadex is recommended for reversal of this deep neuromuscular blockade?

• A2 mg/kg
• B4 mg/kg
• C8 mg/kg
• D16 mg/kg

A 65-year-old male with severe ARDS (PaO2/FiO2 ratio 95 mmHg) is mechanically ventilated. Which of the following parameters conforms to the ARDS Network (ARDSnet) ventilation strategy?

• ATidal volume 8-10 mL/kg of actual body weight; plateau pressure < 35 cm H2O.
• BTidal volume 6 mL/kg of predicted body weight; plateau pressure <= 30 cm H2O.
• CTidal volume 6 mL/kg of actual body weight; PEEP < 5 cm H2O.
• DTidal volume 12 mL/kg of predicted body weight; keep arterial pH > 7.45.

According to the 2021 Surviving Sepsis Campaign guidelines, which of the following represents a key component of the Hour-1 bundle?

• AAdminister a minimum fluid bolus of 30 mL/kg of crystalloid within the first hour for pat…
• BInitiate low-dose dopamine infusion if the patient remains hypotensive despite fluid resu…
• CMeasure blood lactate levels only after starting broad-spectrum antibiotics.
• DAdminister high-dose intravenous corticosteroids to all patients with suspected sepsis.

Which of the following is a key component of the ventilator bundle designed to prevent ventilator-associated pneumonia (VAP) in the ICU?

• AMaintain the patient in a supine position to reduce work of breathing.
• BKeep the head of the bed elevated to 30-45 degrees.
• CPerform routine daily bronchoscopy for secretion clearance.
• DAdminister prophylactic systemic antibiotics daily.

Which of the following is correct regarding the clinical diagnosis of brain death (death by neurological criteria)?

• AThe presence of spinal reflexes (e.g., plantar flexion, triple flexion) excludes the diag…
• BHypothermia (core temperature < 35 degrees C) is required to ensure brain preservation du…
• CDuring the apnea test, the patient is observed for respiratory efforts while PaCO2 is all…
• DElectroencephalography (EEG) is mandatory in all clinical scenarios to confirm brain deat…

A nurse uses the Confusion Assessment Method for the ICU (CAM-ICU) to assess a ventilated patient. Which of the following combinations of features confirms the presence of delirium?

• AFluctuating mental status, inattention, and altered level of consciousness (RASS other th…
• BDepressed mood, inattention, and memory impairment.
• CFluctuating mental status, sleep disturbance, and motor hyperactivity.
• DConstant sedation, disorientation, and auditory hallucinations.

A patient presents to the ICU with severe chronic hyponatremia (sodium 112 mmol/L) and mild confusion. What is the maximum recommended rate of sodium correction in the first 24 hours to minimize the risk of osmotic demyelination syndrome (ODS)?

• A4-6 mmol/L
• B8-10 mmol/L
• C12-15 mmol/L
• D20 mmol/L

According to clinical guidelines (ASPEN/ESICM), which of the following is the most appropriate approach to nutrition in a hemodynamically stable, mechanically ventilated patient in the ICU?

• AStart early enteral nutrition (within 24-48 hours of admission) rather than delaying or s…
• BStart total parenteral nutrition (TPN) immediately on day 1 to prevent caloric deficit.
• CWithhold all nutrition for the first 7 days to let the bowel rest.
• DFeed exclusively via a post-pyloric tube in all patients to prevent microaspiration.

A patient in the ICU with acute kidney injury (AKI) is being assessed for urgent renal replacement therapy (RRT). Which of the following clinical findings represents an absolute indication for starting RRT?

• AMild metabolic acidosis (pH 7.31) with a serum bicarbonate of 18 mmol/L.
• BSerum potassium of 6.8 mmol/L with associated ECG changes (peaked T waves) refractory to…
• CSerum creatinine of 250 umol/L.
• DUrine output of 0.4 mL/kg/h for 6 consecutive hours.

A patient with diabetic ketoacidosis (DKA) has an initial blood glucose of 28 mmol/L, arterial pH of 7.15, and serum potassium of 3.1 mmol/L. Which of the following is the most appropriate first step in management?

• AAdminister an intravenous bolus of 10 units of rapid-acting insulin.
• BStart an insulin infusion immediately at 0.1 units/kg/h and withhold fluid resuscitation.
• CInitiate intravenous fluid resuscitation and add potassium supplementation; withhold insu…
• DInfuse sodium bicarbonate to correct the metabolic acidosis.

A 45-year-old female is admitted to the ICU with severe acute pancreatitis. Which of the following represents the most appropriate initial management strategy?

• AAdminister prophylactic broad-spectrum antibiotics to prevent pancreatic necrosis infecti…
• BKeep the patient nil-by-mouth (NPO) for at least 7-10 days to allow pancreatic rest.
• CInitiate aggressive fluid resuscitation (preferably with Ringer's lactate) and target ear…
• DPerform urgent surgical debridement of pancreatic necrosis within the first 48 hours.

A patient in the ICU develops a 50% drop in platelet count (from 240x10^9/L to 110x10^9/L) on day 6 of therapeutic unfractionated heparin therapy. A diagnosis of Heparin-Induced Thrombocytopenia (HIT) is suspected. What is the most appropriate next step?

• AStop heparin and initiate therapeutic anticoagulation with argatroban.
• BStop heparin and start low-molecular-weight heparin (enoxaparin).
• CStop heparin and transfuse platelets to restore the platelet count.
• DContinue heparin and order a heparin-PF4 ELISA antibody test, waiting for the results bef…

According to the Brain Trauma Foundation guidelines, which of the following represents a target parameter for a patient with severe traumatic brain injury in the ICU?

• AKeep intracranial pressure (ICP) < 22 mmHg and maintain cerebral perfusion pressure (CPP)…
• BMaintain CPP > 80 mmHg by aggressive vasopressor titration to maximize blood flow.
• CHyperventilate the patient to a PaCO2 of 25 mmHg (3.3 kPa) as baseline therapy.
• DKeep ICP < 10 mmHg and maintain cerebral perfusion pressure (CPP) between 40-50 mmHg.

A patient with status asthmaticus is intubated in the ICU due to progressive respiratory failure. Which of the following ventilator strategies is most appropriate to prevent dynamic hyperinflation (auto-PEEP)?

• AHigh respiratory rate (24 bpm) and large tidal volumes (10 mL/kg) to maximize minute vent…
• BLow respiratory rate (8-10 bpm), small tidal volumes (6-8 mL/kg), and a long expiratory t…
• CZero PEEP (ZEEP) and a high inspiratory flow rate to prolong the inspiratory time.
• DMaintain arterial pH > 7.45 by increasing the minute ventilation.

A patient in the ICU with a confirmed massive pulmonary embolism (PE) becomes hypotensive (systolic blood pressure 80 mmHg) and requires a norepinephrine infusion. Echocardiography shows severe right ventricular (RV) dilation and dysfunction. What is the definitive first-line therapy?

• AImmediate systemic thrombolytic therapy (e.g., alteplase).
• BTherapeutic anticoagulation with unfractionated heparin infusion alone.
• CSurgical embolectomy under cardiopulmonary bypass.
• DInsertion of an inferior vena cava (IVC) filter.

According to evidence-based guidelines, which of the following patient scenarios represents a strong indication for stress ulcer prophylaxis in the ICU?

• AA patient admitted with mild sepsis who is tolerating enteral nutrition.
• BA patient requiring mechanical ventilation for more than 48 hours or possessing a coagulo…
• CAll patients admitted to the ICU, regardless of ventilation or coagulation status.
• DA patient recovering from elective uncomplicated laparoscopic cholecystectomy.

To prevent central line-associated bloodstream infections (CLABSI), which of the following is a recommended practice during the insertion of a central venous catheter?

• AAvoid the subclavian vein and use the femoral vein as the first-line site.
• BUse maximum sterile barrier precautions (cap, mask, sterile gown, sterile gloves, and lar…
• CApply a topical antibiotic ointment to the insertion site daily after insertion.
• DRoutinely exchange catheters over a guidewire every 7 days to prevent bacterial colonizat…

A patient who has been in the ICU for 3 weeks for severe ARDS and sepsis is noted to have generalized, symmetrical muscle weakness and difficulty weaning from the ventilator. Electromyography (EMG) shows axonal motor-sensory polyneuropathy. Which of the following is correct regarding ICU-acquired weakness (ICUAW)?

• AIt is primarily caused by the administration of volatile anesthetics.
• BRisk factors include hyperglycemia, prolonged immobilization, sepsis, and the use of cort…
• CCritical illness myopathy (CIM) preserves sensory nerve action potentials, while critical…
• DThe weakness typically spares the diaphragm and facial muscles.

A patient with acute myocardial infarction develops cardiogenic shock (cardiac index 1.6 L/min/m², PCWP 22 mmHg, MAP 55 mmHg). Which of the following is the most appropriate initial vasoactive regimen?

• ANorepinephrine to maintain perfusion pressure (MAP >= 65 mmHg) titrated alongside an inot…
• BHigh-dose phenylephrine to raise systemic vascular resistance.
• CEsmolol infusion to reduce myocardial oxygen consumption.
• DSodium nitroprusside boluses to reduce preload.

A patient is admitted to the ICU with acute liver failure secondary to paracetamol (acetaminophen) overdose. According to the King's College Criteria, which of the following is an indication for emergency liver transplantation?

• AArterial pH < 7.30 after adequate volume resuscitation, regardless of the grade of enceph…
• BSerum creatinine > 150 umol/L.
• CInternational Normalized Ratio (INR) > 3.0.
• DGrade II encephalopathy alone.

A patient is admitted to the ICU after being rescued from a house fire. He is comatose. Pulse oximetry shows oxygen saturation (SpO2) of 98%, but arterial blood gas analysis reveals a carboxyhemoglobin (COHb) level of 35%. Which of the following is correct regarding his management?

• AThe normal SpO2 of 98% rules out tissue hypoxia.
• BAdminister 100% oxygen and arrange for hyperbaric oxygen (HBO) therapy due to loss of con…
• CAdminister a nitroprusside infusion to promote carbon monoxide clearance.
• DRestrict oxygen therapy to avoid oxygen toxicity since the SpO2 is normal.

A patient with chronic post-surgical neuropathic pain is being started on pharmacotherapy. According to international guidelines (e.g., IASP NeuPSIG), which of the following is recommended as a first-line drug class?

• AStrong opioids (e.g., oxycodone)
• BGabapentinoids (e.g., pregabalin or gabapentin) or Tricyclic Antidepressants (e.g., amitr…
• CTopical capsaicin (8% patch) as first-line systemic therapy
• DSelective serotonin reuptake inhibitors (SSRIs, e.g., fluoxetine)

A patient with advanced cancer is currently taking oral morphine 120 mg per day but experiences inadequate pain control and severe myoclonus. The clinical decision is made to rotate to oral oxycodone. Assuming oral morphine is 1.5 times less potent than oral oxycodone, and accounting for incomplete cross-tolerance by reducing the calculated dose by 30%, which of the following represents the most appropriate daily dose of oral oxycodone?

• A180 mg per day
• B80 mg per day
• C56 mg per day
• D40 mg per day

A patient presents with burning pain, swelling, skin color changes, and restricted range of motion in her left hand 3 months after a wrist fracture. Complex Regional Pain Syndrome (CRPS) is suspected. According to the Budapest clinical diagnostic criteria, which of the following is correct?

• AThe diagnosis requires objective evidence of nerve injury (CRPS Type II) on nerve conduct…
• BThe patient must report symptoms in at least 3 of 4 categories (sensory, vasomotor, sudom…
• CA bone scan must be positive to establish the diagnosis.
• DThe symptoms must be restricted to a single peripheral nerve distribution.

When performing a lumbar transforaminal epidural steroid injection (TFESI), which of the following is correct regarding the selection of steroid and safety considerations?

• AParticulate steroids (e.g., methylprednisolone) are preferred for transforaminal injectio…
• BNon-particulate steroids (e.g., dexamethasone) have a lower risk of causing spinal cord i…
• CTransforaminal injections have no risk of intravascular injection, unlike interlaminar in…
• DParticulate steroids are dissolved easily in saline and do not obstruct small capillaries.

A patient with chronic lower back pain is suspected of having lumbar facet joint arthropathy. To confirm the diagnosis and determine suitability for radiofrequency neurotomy (RFN), which of the following diagnostic procedures is most appropriate?

• AIntra-articular facet joint injections.
• BDiagnostic medial branch blocks (MBBs) of the primary dorsal rami supplying the target jo…
• CEpidural steroid injection.
• DMagnetic resonance imaging (MRI) of the lumbar spine alone.

When prescribing intravenous Patient-Controlled Analgesia (PCA) morphine for an opioid-naive adult patient in the acute postoperative period, which of the following settings is recommended for safety?

• APrescribe a continuous background infusion of 1-2 mg/h to ensure adequate sleep.
• BAvoid a continuous background infusion; use demand-only dosing with an appropriate lockou…
• CUse a lockout interval of 2 minutes to allow rapid titration of pain.
• DSet a maximum 4-hour limit but bypass the lockout interval.

A patient on high-dose oral morphine for chronic back pain reports that his pain has progressively worsened and spread to new areas of his body. He describes the pain as a burning sensation, and light touch of the skin causes discomfort (allodynia). Increasing his morphine dose has exacerbated his symptoms. Which of the following is the most likely diagnosis, and what is the appropriate management?

• AOpioid tolerance; immediately double the morphine dose.
• BOpioid-induced hyperalgesia (OIH); gradually taper and reduce the morphine dose, and cons…
• CNeuropathic progression; add high-dose fentanyl patches.
• DOpioid withdrawal; administer naloxone.