MD Anesthesia - Paper IV: Recent Advances in Anaesthesia

Question Bank for RGUHS September 2026 Examination

SECTION A: NEW DRUGS IN ANAESTHESIA

Remimazolam

1. [Long Essay / 20 marks] Describe the pharmacology of Remimazolam. Compare it with Propofol as an induction and maintenance agent for general anaesthesia. Discuss its clinical advantages and limitations.
2. [Short Essay / 10 marks] Remimazolam - pharmacokinetics, mechanism of action, and clinical applications.
3. [Short Essay / 10 marks] Compare Remimazolam and Propofol in terms of: (a) pharmacokinetics (b) haemodynamic effects (c) reversal (d) postoperative delirium.
4. [Short Note / 5 marks] Ciprofol as an induction agent - mechanism and advantages over Propofol.
5. [Short Note / 5 marks] Why is Remimazolam considered safer than Propofol in haemodynamically compromised patients?

Sugammadex and Neuromuscular Monitoring

1. [Long Essay / 20 marks] Discuss the problem of residual neuromuscular blockade (RNMB). How has Sugammadex changed perioperative neuromuscular blockade management? Compare Sugammadex with Neostigmine.
2. [Short Essay / 10 marks] Sugammadex - structure, mechanism of action, dosing for reversal of rocuronium/vecuronium, and precautions.
3. [Short Essay / 10 marks] Quantitative neuromuscular monitoring - methods (acceleromyography, electromyography), clinical significance, and the Train-of-Four ratio.
4. [Short Note / 5 marks] What is "deep neuromuscular blockade" and what are its surgical advantages?
5. [Short Note / 5 marks] Interactions between Magnesium sulfate and Sugammadex - clinical implications.

Dexmedetomidine

1. [Short Essay / 10 marks] Dexmedetomidine - pharmacology, clinical uses in analgosedation, opioid-free anaesthesia, and awake fibreoptic intubation.
2. [Short Note / 5 marks] Alpha-2 agonists in perioperative medicine - opioid-sparing effects and haemodynamic profile.

SECTION B: REGIONAL ANAESTHESIA - FASCIAL PLANE BLOCKS

1. [Long Essay / 20 marks] Describe Erector Spinae Plane (ESP) block - anatomy of the plane, technique of ultrasound-guided injection, mechanism of spread, clinical applications (thoracic, cardiac, abdominal, spine surgery), and evidence base.
2. [Short Essay / 10 marks] Erector Spinae Plane block vs. Thoracic Paravertebral block - compare anatomy, technique, spread, complications, and indications.
3. [Short Essay / 10 marks] Quadratus Lumborum (QL) block - approaches (anterior, lateral, posterior, intramuscular), anatomy, clinical applications in abdominal and hip surgery.
4. [Short Essay / 10 marks] Transversus Abdominis Plane (TAP) block - landmark vs. ultrasound-guided technique, variants (posterior, lateral, subcostal), and indications.
5. [Short Essay / 10 marks] PECS I and PECS II blocks - anatomy, technique, and role in breast surgery analgesia.
6. [Short Note / 5 marks] Serratus Anterior Plane (SAP) block - anatomy and clinical application.
7. [Short Note / 5 marks] Adductor Canal Block vs. Femoral Nerve Block for knee arthroplasty analgesia - why is ACB preferred?
8. [Short Note / 5 marks] IPACK block (Infiltration between the Popliteal Artery and Capsule of the Knee) - describe technique and advantage.
9. [Short Note / 5 marks] Fascial plane blocks in obstetric anaesthesia - list four blocks used post-Caesarean section with indications.

SECTION C: TOTAL INTRAVENOUS ANAESTHESIA (TIVA) AND TARGET-CONTROLLED INFUSION (TCI)

1. [Long Essay / 20 marks] Total Intravenous Anaesthesia (TIVA): Define TCI and TIVA. Describe the pharmacokinetic models used (Marsh, Schnider, Minto). Compare TIVA with inhalational anaesthesia in terms of PONV, recovery, awareness, cancer surgery outcomes, and environmental impact.
2. [Short Essay / 10 marks] Target-Controlled Infusion (TCI) - pharmacokinetic compartment models, effect-site vs. plasma targeting, Ke0, context-sensitive half-time.
3. [Short Essay / 10 marks] Inhalational anaesthesia vs. TIVA for cancer surgery - discuss the immunological differences and evidence for oncological outcomes.
4. [Short Note / 5 marks] PONV prophylaxis - current guidelines (SAMBA/ESAIC), high-risk Apfel scoring, and role of TIVA.
5. [Short Note / 5 marks] Automated/closed-loop anaesthesia delivery - concept, components, and future directions.
6. [Short Note / 5 marks] Environmental impact of volatile anaesthetics (desflurane phased out) - global warming potential comparison.

SECTION D: AIRWAY MANAGEMENT - RECENT ADVANCES

1. [Long Essay / 20 marks] Video laryngoscopy in airway management - classification of devices (hyperangulated vs. standard geometry), evidence vs. direct laryngoscopy, role in anticipated and unanticipated difficult airway, and integration into difficult airway algorithms (DAS 2015, ASA 2022 update).
2. [Short Essay / 10 marks] Updated Difficult Airway Management algorithms (DAS 2015 / ASA 2022) - describe the "can't intubate, can't oxygenate" (CICO) drill.
3. [Short Essay / 10 marks] High-flow nasal oxygen (HFNO / Optiflow) - physiological basis (apnoeic oxygenation), clinical applications in preoxygenation, difficult airway, and ICU.
4. [Short Essay / 10 marks] Supraglottic airway devices - second-generation LMAs (ProSeal, Supreme, i-Gel, LMA Protector) - features, differences from first-generation, and role in difficult airway.
5. [Short Note / 5 marks] THRIVE technique (Transnasal Humidified Rapid Insufflation Ventilatory Exchange) - principle and clinical use.
6. [Short Note / 5 marks] Videolaryngoscope vs. fibrescope - when to choose which for anticipated difficult intubation?
7. [Short Note / 5 marks] Role of airway ultrasound - assessment of ETT position, cricothyroid membrane identification, subglottic air column sign.

SECTION E: ENHANCED RECOVERY AFTER SURGERY (ERAS)

1. [Long Essay / 20 marks] Enhanced Recovery After Surgery (ERAS) - principles, components of a multimodal ERAS protocol (preoperative, intraoperative, postoperative elements), evidence base, and role of the anaesthesiologist. Give examples for colorectal, cardiac, or obstetric ERAS.
2. [Short Essay / 10 marks] Multimodal analgesia and opioid-sparing strategies - describe the use of paracetamol, NSAIDs, ketamine, alpha-2 agonists, gabapentinoids, and regional blocks as adjuncts.
3. [Short Essay / 10 marks] Perioperative goal-directed fluid therapy (GDFT) - monitoring tools (pulse pressure variation, stroke volume variation, oesophageal Doppler), algorithms, and evidence.
4. [Short Note / 5 marks] Opioid-free anaesthesia (OFA) - rationale, drug combinations used, and patient populations that benefit most.
5. [Short Note / 5 marks] Prehabilitation before major surgery - components and evidence for improved postoperative outcomes.

SECTION F: POINT-OF-CARE ULTRASOUND (POCUS) IN ANAESTHESIA

1. [Long Essay / 20 marks] Point-of-care ultrasound (POCUS) in anaesthesia - describe applications in: (a) gastric volume assessment (b) cardiac function (basic TTE windows) (c) lung ultrasound (d) vascular access (e) nerve blocks. Discuss the training requirements.
2. [Short Essay / 10 marks] Ultrasound assessment of gastric volume before emergency surgery - technique (antrum grading), clinical decision-making, and evidence.
3. [Short Essay / 10 marks] Lung ultrasound in the ICU and perioperative setting - B-lines, A-lines, lung sliding, consolidation, pleural effusion, and pneumothorax patterns.
4. [Short Note / 5 marks] Focused cardiac ultrasound (FoCUS) - FATE protocol, four basic windows, and what can be assessed.
5. [Short Note / 5 marks] POCUS for obstetric anaesthesia - spinal landmark identification, LV function assessment, and gastric content grading.

SECTION G: PAIN MEDICINE - RECENT ADVANCES

1. [Long Essay / 20 marks] Chronic postoperative pain (CPOP) - definition, risk factors, pathophysiology (central sensitisation, neuroplasticity), prevention strategies (regional anaesthesia, ketamine, gabapentinoids), and management.
2. [Short Essay / 10 marks] Ketamine as an anaesthetic adjunct - sub-anaesthetic doses for opioid-sparing, NMDA receptor antagonism, prevention of opioid-induced hyperalgesia, and use in opioid-tolerant patients.
3. [Short Essay / 10 marks] Spinal cord stimulation (SCS) - mechanism, burst stimulation vs. conventional SCS, and indications (failed back surgery syndrome, CRPS, ischaemic pain).
4. [Short Essay / 10 marks] Role of IV Lidocaine infusion in perioperative pain management - mechanism, evidence in abdominal and thoracic surgery, dosing, and safety concerns.
5. [Short Note / 5 marks] Erector Spinae Plane block for cancer pain relief - mechanisms and evidence (2024 systematic review).
6. [Short Note / 5 marks] Tapentadol vs. Tramadol - mechanism of action (MOR agonism + NRI), advantages, and role in multimodal analgesia.
7. [Short Note / 5 marks] Transforaminal vs. interlaminar epidural steroid injection for disc-related radiculopathy.

SECTION H: INTENSIVE CARE MEDICINE - RECENT ADVANCES

1. [Long Essay / 20 marks] Sepsis-3 definition and management - discuss the Sepsis-3 definition (2016), quick SOFA (qSOFA), Surviving Sepsis Campaign (SSC) 2021 guidelines, "Hour-1 Bundle," vasopressor choices, and controversies.
2. [Short Essay / 10 marks] Acute Respiratory Distress Syndrome (ARDS) - Berlin definition, lung-protective ventilation (low tidal volume, PEEP strategies, driving pressure), prone positioning evidence (PROSEVA trial), and salvage therapies (inhaled nitric oxide, ECMO).
3. [Short Essay / 10 marks] ECMO (Extracorporeal Membrane Oxygenation) - types (VV-ECMO vs. VA-ECMO), indications (refractory ARDS, cardiogenic shock, cardiac arrest), complications, and outcomes.
4. [Short Essay / 10 marks] Ventilator-associated pneumonia (VAP) - pathogenesis, prevention bundle (HOB elevation, oral care, SDD), diagnosis (CPIS score), and antimicrobial management.
5. [Short Note / 5 marks] Permissive hypercapnia - rationale, physiological effects, and limits.
6. [Short Note / 5 marks] Deresuscitation in the ICU - rationale for fluid removal after initial resuscitation, tools (SOSD score, diuretics, ultrafiltration).
7. [Short Note / 5 marks] Liberation from mechanical ventilation - spontaneous breathing trial (SBT) protocols, weaning parameters, high-flow nasal oxygen post-extubation.
8. [Short Note / 5 marks] Point-of-care lactate in sepsis - significance of lactate clearance and lactate-guided resuscitation.

SECTION I: ARTIFICIAL INTELLIGENCE AND TECHNOLOGY IN ANAESTHESIA

1. [Long Essay / 20 marks] Artificial Intelligence (AI) and Machine Learning (ML) in anaesthesia - applications in: (a) depth of anaesthesia monitoring (b) preoperative risk scoring (c) automated drug delivery / closed-loop TIVA (d) operating room management (e) early warning systems. Discuss limitations and ethical considerations.
2. [Short Essay / 10 marks] Closed-loop anaesthesia - concept, components (sensor + controller + effector), current evidence, and limitations.
3. [Short Note / 5 marks] Processed EEG monitors (BIS, Entropy, Sedline, Narcotrend) - how do they work? Compare their performance in depth of anaesthesia monitoring.
4. [Short Note / 5 marks] AI-based difficult airway prediction - describe one validated AI model and its clinical utility.

SECTION J: OBSTETRIC ANAESTHESIA - RECENT ADVANCES

1. [Short Essay / 10 marks] Dural puncture epidural (DPE) technique - mechanism, advantages over standard epidural and CSE, and evidence for obstetric analgesia.
2. [Short Essay / 10 marks] Prevention and management of spinal hypotension during Caesarean section - role of prophylactic phenylephrine infusion vs. norepinephrine, fluid preloading vs. co-loading.
3. [Short Note / 5 marks] Programmed Intermittent Epidural Bolus (PIEB) vs. continuous epidural infusion for labour analgesia - mechanism and evidence.
4. [Short Note / 5 marks] Management of anaesthesia in a patient with placenta accreta spectrum disorder - challenges and techniques.

SECTION K: NEUROANESTHESIA AND MONITORING

1. [Short Essay / 10 marks] Near-infrared spectroscopy (NIRS) / cerebral oximetry - principle, clinical applications in cardiac surgery, carotid endarterectomy, and paediatric anaesthesia.
2. [Short Essay / 10 marks] Perioperative neurocognitive disorders (PND) - spectrum (POD, POCD, PODS), risk factors, pathophysiology, prevention (dexmedetomidine, BIS-guided anaesthesia, multimodal ERAS), and relevance for the elderly.
3. [Short Note / 5 marks] Remimazolam in neuroanesthesia - advantages over propofol for patients with compromised neurovascular reserve.

SECTION L: PAEDIATRIC ANAESTHESIA - RECENT ADVANCES

1. [Short Essay / 10 marks] Neurotoxicity of anaesthetic agents in neonates and infants - animal vs. human evidence (GAS trial, PANDA trial), current FDA/WHO advice, and implications for clinical practice.
2. [Short Essay / 10 marks] Caudal epidural block in paediatric anaesthesia - adjuvants (dexmedetomidine, morphine, clonidine, ketamine) to prolong duration - evidence, doses, and safety.
3. [Short Note / 5 marks] TIVA in children - paediatric Propofol pharmacokinetics, Paedfusor and Kataria models.

SECTION M: CARDIAC AND THORACIC ANAESTHESIA

1. [Short Essay / 10 marks] Perioperative management of patients on anticoagulants - DOACs (apixaban, rivaroxaban, dabigatran): timing of discontinuation before neuraxial anaesthesia (ASRA 2022 guidelines), reversal agents (andexanet alfa, idarucizumab).
2. [Short Essay / 10 marks] Lung-protective ventilation during one-lung ventilation (OLV) - tidal volume targets, PEEP strategy, driving pressure, and management of hypoxia.
3. [Short Note / 5 marks] Transcatheter aortic valve implantation (TAVI) - anaesthetic considerations: GA vs. conscious sedation, monitoring, complications.

SECTION N: COAGULATION AND TRANSFUSION - RECENT ADVANCES

1. [Short Essay / 10 marks] Viscoelastic haemostatic assays (VHAs) - TEG and ROTEM: principles, parameters (R time, K time, alpha angle, MA, LY30), clinical application in massive haemorrhage and liver transplant.
2. [Short Essay / 10 marks] Patient Blood Management (PBM) - three pillars, perioperative anaemia management (IV iron, EPO), cell salvage, and restrictive transfusion thresholds (haemoglobin triggers from recent RCTs).
3. [Short Note / 5 marks] Tranexamic acid in surgical bleeding - mechanism, CRASH-2 trial context, perioperative dosing, and contraindications.

SECTION O: SIMULATION AND EDUCATION

1. [Short Note / 5 marks] High-fidelity simulation in anaesthesia training - types of simulators, applications, and evidence for improved patient safety.

PREVIOUS YEAR QUESTION PAPER PATTERN (October 2023 - RGUHS Paper IV)

• Anaesthetic management of specific patient scenarios
• Blood transfusion techniques and complications
• Recent advances across monitoring, drugs, and regional techniques

• 2 Long Essays x 20 marks = 40 marks
• 6 Short Essays x 10 marks = 60 marks
• Total = 100 marks

TOP 10 HIGHEST-PRIORITY TOPICS FOR SEPTEMBER 2026

KEY REFERENCES TO CITE IN ANSWERS

• Fuchs-Buder T et al. (2023). Peri-operative management of neuromuscular blockade: ESAIC guideline. Eur J Anaesthesiol. [PMID 36377554]
• Daccache N et al. (2025). TIVA vs. inhalation - systematic review and meta-analysis. Br J Anaesth. [PMID 40074622]
• Suga M et al. (2025). Postoperative delirium: remimazolam vs. propofol meta-analysis. J Clin Anesth. [PMID 39832842]
• Feng Y et al. (2026). Clinical practice guidelines for TIVA. Br J Anaesth. [PMID 41238462]
• Campbell S & Chin KJ (2022). Erector spinae block: beyond the torso. Curr Opin Anaesthesiol. [PMID 35942700]
• Aleshi P et al. (2025). POCUS in obstetric anesthesia clinical practice. Curr Opin Anaesthesiol. [PMID 40207561]
• Zhu N & Li Y (2025). Sugammadex vs. neostigmine - systematic review and meta-analysis. Biomol Biomed. [PMID 40754949]

• For Long Essays: use the framework - Definition → Classification → Mechanism/Pharmacology → Clinical Application → Evidence/Trials → Advantages/Disadvantages → Future Directions
• Always draw a labelled diagram for regional block questions (anatomy, ultrasound image plane, needle position)
• For drug comparison questions, use a tabular format - examiners appreciate structured comparisons
• Cite at least one landmark trial or recent guideline per answer (e.g., PROSEVA for ARDS, CRASH-2 for TXA, GAS trial for paediatric neurotoxicity)
• Under "recent advances," connecting a classical topic to its latest update (e.g., "the 2025 ASRA guideline now recommends 48 hours for apixaban before neuraxial block") scores distinction marks