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Pain Control II > 2/27 - GA > Flashcards

2/27 - GA Flashcards

1
Q

IV sedation definiti

A

administration of a drug which results in the depression of the CNS

the goal is to produce a state of sedation in which the patient
maintains protective reflexes, and the respiratory and caridovscular systems are minmially affected

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2
Q

rapid onset of IV?

A

yes - the arm to brain circulation is approx 20-25 seconds

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3
Q

advantages of IV sedation

A
  1. rapid onset
  2. titration
    - the drug dosage may be tailored
    - suitable level of sedation
    - shorter recovery periods
  3. continous IV infusion
    - patent vein is maintained throughout procedure
  4. side effects of nausea and vomiting
    - rare when administrated as suggested (titrated)
  5. salivation
    - control of salivary secretions is possible through the administration of antcholinergics
  6. gag reflex
    - is diminished
  7. diminish motor disturbances- diminish seizure activity
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4
Q

titration

A

titration

  • the drug dosage may be tailored
  • suitable level of sedation
  • shorter recovery periods

advantage of IV sedation

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5
Q

titration

A

titration

  • the drug dosage may be tailored
  • suitable level of sedation
  • shorter recovery periods

advantage of IV sedation

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6
Q

disadvanta ges of IV

A

venipuncture is necessary

complications may arise at the site of venipuncture

monitoring **– must be more intensive than that rewuired in most other conscious sedation techniques

revoery not complete – Escort is needed

most IV agents CAN NOT BE reversed – have to be metabolized first

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7
Q

indications for IV sedation

A
  1. anxiety and fear
  2. mentally or physically disabled
  3. age - infants and children
  4. amnesia
  5. med compromised patients
    - angina
    - HBP
    - previous myocardial infarcatin
    - previous cerebrovascular accident
    - epilepsy
  6. control of secretions
  7. analgesia
  8. diminished gagging
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8
Q

contraindications so IV sedation

A

lack of proper training

pregnancy - relative contra

  1. hepatic disease due to liver metabolism
  2. thyroid dysfunction
    hyper - thyroid strom could develop

low thyroid - may not metabolize as well

  1. adrenal insufficiency - crisis
  2. adrenal insufficiency

patients receiing MAOI’s or TCA’s
- go into seratonin syndrome

extremley obese

inadequte veins

allergy to medications

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9
Q

preganncy in IV sedaion

A

relative contraindication – bcause most CNS depressants cross the placenta – into the fetus and may produce birth defects in the developing fetus

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10
Q

briefly exaplin anesthesia as a continuum

A

can eassily move from a deep sedation to GA

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11
Q

ultra-light GA

A

outpatient general anesthesia using IV barbiturates

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12
Q

advantages of general anesthes eia

A

cooperation not essential

patient is unconscious

patient does not respond to pain

amnesia is present (they dont remember)

GA may be the only technique that will prove successful for certain patients

rapid onset

tritration is possible

success rate is 100%

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13
Q

disadvantages of GA

A

patinet unconscious

protective reflexes are depressed

vital signs are depressed

advanced training

anesthesia team is required

special equipment

recovery area must be available

intra-operative and postanestetic complications are more common

patient receiving GA must receive nothing by mouth for 6 hours beore the procedure

patients receiving GA must be evaluated more extensively preoperatively than patients receiving minimal or moderate sedation

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14
Q

contraindications to GA

A

lack of trining

lack of adequatley trained personnel

lack of adequate equipment or facilitities

ASA IV and certain ASA III medically compromised patients

Hx of poliomyelitit in which chest muscles have been involved

Hx of Myasthenia gravis

obese

patients with significantly decreased cardiac and / or pulmonary reserve

patients with a history of malignant hyperthermia

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15
Q

ASA types contraindicated in GA

A

ASA IV and some ASA III

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16
Q

indications for GA

A

extreme anxiety o fear

mentally or physiclly disabled

age - infants and children

short or long traumatic procedures

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17
Q

benefits of outpatient GA v s inpatient

A

economics - cost is cheeper outpatient

psychological benefits

reduced exposure to nonsocomial infections

parental preference

inpatient is in hospital

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18
Q

types of GA

A

in - office outpateitn GA
- IV anesthesia - less than 30 minutes
conventional operating theater type of GA more than 30 mins - less than 4 hours

inpatient type

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19
Q

outpatient GA IV using?

A

propofol or barbiturates

N2O2-O2 (along with the case)

benzodiazepine / versad

opiods - like fentynol

LA* - block of the responses

  • like what you see in the oral surgery clinic
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20
Q

outpatient GA -conventional type of operating room GA

A

used in cases 30 mins to 4 hours

patient undergoes same GA prep as the inpatient

limited to ASA I and II – selected III

completed training in anesthesiology

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21
Q

inpatient GA

A

patient admitted to hospital prior to procedure

undergoes workup to determine risk , undergoes procedure and then remains in hospital post-op

ANesthesiologist is responsible for the administration for the anesthetic* (vs outpatient - you have to be certified)

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22
Q

armamentarium

A 
anesthesia machine
IV equip
ancillary anesthesia equipment 
monitoring equip 
emergency equipment and drugs
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23
Q

ancillary anesthesia equipment

A

face masks and appropriate connectors

laryngoscopes, blades

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24
Q

monitoring equipment

A

stethoscopes

  • precordial
  • pretracheal
  • esophageal
pulse oximeter
end-tidal CO2
blood pressure cuff
ECG
temperature
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25
Q

TIVA

A

total inervenous anesthesia

  • a continous IV infusion is commonly used for all general anesthetic procedures
  • indwelling catheters are preferred
  • tubing and bags of IV solution are requred
  • disposable syringes and needles should be available
  • adhesive tape
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26
Q

endotracheal tubes and connectors

A

part of armamentarium

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27
Q

LMA

A

laryngeal mask airways
- acts like an endotracheal tube

does not get fully patent airway
- used in the field more

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28
Q

Bispecteral electroencephalographic monitoring

A

BIS monitoring

-

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29
Q

intra arterial blood pressure

A

degree of accuracy is great but not really needed during outpaient sedation

indicaed in both general anesthetic proccedures involving greater degree of risk
- neuro or cardiac surgery
and when degree of risk presented by the patient (ASA IV or V) is significant

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30
Q

types of benzodiazepines used

A

diazepam - valium

midazolam - versed

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31
Q

mechanism of benzo’

A

becoming less excitebale

binds to stereospecific benzo recepetors on the postsynaptic GABA neuron at several sites within the central nervous system, including the limbic system, reticular formation

increase inhibitory effect of GABA by increased neuronal excitablility - INCREASE PERM TO CHLORIDE IONS

  • hyperpolarization – less excitable state
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32
Q

contraindications to benzo

A

allergy to diazepam

acute narrow glaucoma and wide angle glacuoma

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33
Q

contraindications to benzo of valium (diazepam)

A

allergy to diazepam

acute narrow glaucoma and wide angle glacuoma

psychosis

pregnancy

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34
Q

versed aka

A

midazolam - benzo

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35
Q

used more versed vs valium

A

versed – need to know the comparisons of these

versed is more potent

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36
Q

barbiturates?

their indication

A

not used as much today but served a lot in terms of sedative drugs

can produce any level of sedation ranging from light sedation through hypnosis - GA , coma and death

indication – induction and maintenance of GA anesthesia for short procedure

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37
Q

pentobarbital

A

barbitruate

classified as short acting barbiturate
IV sedation
seizure control

effects and side effects

  • reduces cerebral metabolism
  • modest decrease in blood pressure
  • temporary respiratory depression
  • hangover effect
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38
Q

reversal agent to benzo

A

flumazenil

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39
Q

flumazenil

A

reversal agent to benzo

contraindicated in

  • allergy to benzo or flumazenil
  • if being treated for stuff on benzo’s like status epilepticus, or control of intracranial pressure
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40
Q

opioid antagonist

A

naloxone

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41
Q

most commonly used inhalation

A

nitrous

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42
Q

nitrous oxide not used for GA?

what is its use

A

not strong enough – not potent enough

MAC is not high enough to get to general - it is 104-105%

second gas effec**

43
Q

primary function of nitrous oxide in GA?

A

SECOND GAS EFFECTS

in GA it is used to potentiate the actions of the other more potent drugs (IV or inalation) and thus permits a smaller dose or lesser concentration of this drug needed to produce the desired level of GA

44
Q

neuroleptanesthesia

produced how?

A

type of GA that is produced by the administration of
neuroleptic drug
- and an opioid are administered together characterized by
- sleepiness, psychological indifference to environment, no voluntary movements, analgesia, satisfactory amnesia

produced by administering?

***(droperidol) = neuroleptic drug (does have black box warning)

  • opiod - fentanyl
  • nitrous oxide -oxygen
  • muscle relaxant
45
Q

dissociative anesthesia

A

type of GA
- dissociative anesthesia and analgesia as produced by KETAMINE

patient appears to be awake

maintain many reflexes

unaware of,or dissociate from the environment

eyes open - may see nystagmus

46
Q

disadvantages of ketamine / contraindications

A

used in dissociation anesthesia (type of General)

increased heart rate, blood pressure and intraoclular pressure

eye movements and nystagmus can occur

no antagonist is available for it

can produce a confused state, associated with unpleasant dreams and frightening hallucinatins
(more common to occur with adults ) – so use with a benzzo

47
Q

contraindications to ketamine

A

intraocular surgery, patietns with history of increased CSF pressure, CVA, psychiatric problems , and HTN

48
Q

four mechanisms of muscle relaxants

A

muscular blocking agents
- interfere with the transmission of impulses from motor nerves to muscles at the skeletal neuromuscular junction

  1. deficiency block
  2. nondepolarizing block
  3. depolarizing block
  4. dual block
49
Q

no drug ever exerts a single action?

A

true

50
Q

william harvey

A

provided much of the groundwork for the future of IV medication - stating that there was a continuous circulation of blood within a closed system

showed that because of valves in heart and veins - blood flow within circulatory system was unidirectional

51
Q

jorgensen

A

first to use IV route for premedication

combo of barbiturate (phentobarbital and opioid (meperidine) and scopolamine

52
Q

mcantosh blade is ?

miller blade is?

A

mcantosh is curved

miller is straight

53
Q

miller straight blade into the oral cavity?

A

underneath the epiglottis

54
Q

mcantosh blade into the oral cavity?

A

curved so want it – go into velecula
NOT under the epiglottis

do NOT rotate on it – b/c if you do then you can hit the maxillary teeth

55
Q

oropharyngeal and nasopharyngeal airways?

A

if using oropharyngeal airway – patient has to be out - if semi-conscious they can choke on it

nasopharyngeal airway - semi-conscious

measure from corner of mouth to angle of the mandible

56
Q

pretracheal stethescope

A

around the trachea - and can pick up on breath sounds
- gurgling

obstruction early
different wave form

57
Q

esophageal stethescope

A

for patient already intubiated and able to hear heart sounds better as well

can add a thermometer and get a core temperature reading

58
Q

why temp

A

making sure patients – especially younger populations are not going through malignant hypothermia

59
Q

Not commonly used monitors

A

EEG
arterial blood pressure

Central venous pressure (CVP) - invasive and goes into the atrium

collection and measurments of urine output

60
Q

EEG

A

gets a number
shows the person is sedation

electroencephalogram
identifying hypnotic effects of anesthersia

BIS (bispectral) index - continuous EEG parameter that ranges from awake - no drug to effect value of 95-100

61
Q

intra arterial blood pressure

A

CONTINOUS blood pressure
artery
radial artery
more in the obese patient

degree in accuracy is great but not really needed during outpatient

indicated in GA involving greater risk - neuro or cardiac surgery or when patient is ASA III

NOT needed during outpatient setting -

62
Q

opiod agonist / antagonisht?

A

pentazocine

nalbuphine

63
Q

anticholinergics

A

atropine

scopolamine

64
Q

antidotal drugs

A

flumazenil - reverses benzo’s

65
Q

indications for valium

A

oral med for preopertative dental anxiety
sedative component in IV sedation in oral surgery
skeletal muscle relaxant

medical - management of anxiety disorders, alcohol withdrawl symptoms, skelteal muscle relaxant and convulsive disorders

66
Q

eyelid halfway over pupil?

A

veral sign

know in good state of relax

67
Q

indications for versed

A

Miazolam ( m =more - using it more)

dental - sedation component in IV sedation in OS patients
syrup formulation used in children to help alleviate anxiety before dental procedure

medical - preoperative sedation and provides IV ssedation prior to diagnostic or radiographic proceddures

68
Q

amnesia produced in midazolam and diazepam

A

anterograde

better in midazolam / versed – “need to foreget - versed”

69
Q

biotransformation of midazolam and diazepam

A

midazolam = 1.7- 2.4 hours

vs diazepam = 31/3 hr

70
Q

which benzo has pain on injection and why?

A

diazepam and b/c of its medium - of propylene glycol
* so put into bigger vein so it does not irritate it as much

*none in midazolam because versed / midazolam is WATER BASED

71
Q

what benzo to use when the patient needs to forget?

A

VERSED – midazolam

72
Q

respiratory system effect of diazepam vs midazolam

A

diazepam causes more depression

73
Q

analgesic with the benzo?

A

NO

74
Q

sedation effect with midazolam and diazepam

A

higher levels of sedation with diazepam / valium

than midazolam / versed

75
Q

biggest reason why people started using midazolam over diazepam

A

because of the differences in the half lives of them

active metabolite half life of midazolam is less than that of diazepam

*but versed is more potent

76
Q

contraindications for barbs

A 
allergy 
uncontrolled pain 
addiction to sedative hypnotics 
porphyria 
respiratory diseasae with dyspnea or obstruction
77
Q

reversal agent to barbiturates?

A

no

78
Q

pharmacology of barbs

A

no effect on pain threshold except in doses that affect level of consciousness

anticonvulsant properties

eliminated by biotransformation in the liver and excretion through the kidneys

79
Q

indications for opiod agonists

A

supplementatino of GA
Pain releif
premedication

80
Q

conraindications for opioid agonists

A

allergy
COPD and decrease respiratory reserve

patietns receiving MAO inhibitors within the previous 14 days

increased inracranial presure

81
Q

side effects of opiod agonist

A 
resp deprssion
nausea / vomitt
hypotension 
drowsniness 
histamine release
82
Q

fentanyl aka? what type? indications

A

sublimaze - opiod agonist

dental - adjunct in preoperative IV sedation in patients going surgery

medical - sedation - releief of pain, preop med, adjunct to general or regional anesthesia, management of chronic pain

83
Q

side effects of fentanyl / submlimaze

A

rapid IV infusion may result in skeletal muscle and chest wall rigidity , impaired ventilation, respiratory distress, apnea, bronchoconstriction, laryngospasm

INJECT SLOWLY over 3-5 minutes, non-depolarizing skeletal muscle relaxant may be required

84
Q

dosage of flumazenil

A

benzo antagonist

.2mg IV repeat 1 minute interval

average reversal dose is .2mg

max dose is 1.0 mg

given IV

do NOT give patients being treated for status epilepticus, or control of intracranial pressure (can increase it)

85
Q

naloxone hydrochloride

A

opiod antagonist
- contraindications
opiod dependence and allergy

dose is .1 to .2 mg IV over 2-3 minutes

average reversal dose is .4 mg

max dose is 1.2 mg for adult

86
Q

types of GA

A
  1. inhalation anesthetics
    - most frequently used means of producing general anesthesia
  2. neuroleptanesthesia
  3. dissociative anesthesia
87
Q

halothane

A

inhalation
MAC of .75% - pretty potent
- rarely used

disadvantages
- myocardial depression, produces cardiac dsyrhthmias, sensitization of myocardium to actions of catecholamines , potent urine relaxant, possible hepatic necrosis

have to be aware if using this with vasoconstrictors

88
Q

enflurane

A

MAC of 158%
compatible with epinephrine
good for asthmatics

pleasant odor, rapid inductin, nonirritating, BRONCHODILATOR, good muscle relaxatnt, no dysrrthmias, non an emetic, nonexplosive and non flammable

89
Q

isoflurane

A

MAC 1.28%

pleasnat odor, rapid inductino, nonirritating , bronchodilatort, muscle relaxant, stable cardaic rhythm, compatible with epi,

disadvantages
- myocardial depression, depressed BP, postanesthetic shivering, not given to decreased renal renal function

90
Q

sevoflurane * noted for?

A

MAC 1.71%
used fo outpatient more

LOW SOLUBILITY , rapid induction and emergence from anesthesia,
less irritating to the airway

*commonly used inhalation anesthetic in ambulatory dental anesthesia cases

91
Q

desflurane

A

irritating - unpleasant odor - so NOT RECOMMENDED for induction because of this

MAC 4.6-6.0%

rapid onset and recovery
- recovery seems to be advantage

92
Q

patent airway can be maintained with ketamine? advantages?

A

yes

non irritating to bloos vessels and tissues, muscle tone is preserves and laryngeal and pharyngeal reflexes are not depressed

can use in children

used in patietns who are hemodyanmically unstable or hypovolemic - b/c it can increase blood pressure

can be used with asthmatic patients

93
Q

increase salivation?

A

ketamine

94
Q

dysphoric emergence with?

A

ketamine – so use a benzo with it

greater chance happening if older

95
Q

antagonist to ketamine

A

no

96
Q

indications for propofol

A

induction of anesthesia
maintenaince of anesthesia
postop antiemetic

mechanism of action

  • hindered phenolic compound
  • UNRELATED to any other barbs, opioid, benzo o

careful in older adults - but only major disadv is pain on injection

97
Q

deficiency block

A

muscle relaxent

  • synthesis and/ or transmission of acetycholine is interfered with
  • neomycin, kenamycin, clostridiu botulinum
98
Q

non- depolarizing block

A

muscle relaxant

  • COMPETITVE BLOCK
  • drug attaches to cholinergic receptors , preventing acetycholine from attaching to the receptor (curare, pancuronium
99
Q

depolarizing block

A

muscle relaxant

- dru acts in a manner similar to acetycholine but for prolong period of time (succinycholine)

100
Q

dual block

A

muscle relaxant
DESENSITIZATION BLOCK
- the membrane is depolarized (phase 1) and then is slowly repolarized
drug enters into the fiber and acts as a nondepolarizing agent (phase II)

101
Q

pre-oxidate

then

A

relaxe - versed

then fentynol

breathing 
then propofol (put to sleep)

then muscle relaxant

laryngoscope ready

102
Q

purposes of record keeping

A
  1. trend plot of vital
  2. as an aid to the clinicians memory
  3. as a documentation of a patients response to the administration of drugs and the operative procedure
  4. nonclinically - as a legal document
103
Q

eating and drinking before surgery

A

nothing after midnight

if infant - no solid food or milk 6 hours before - clear liquids up to 4 hours before

Pain Control II (15 decks)

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