4. Ambulatory Anesthesia Flashcards by J L

Potential Candidates
• \_\_\_\_ or fearful
• Young children
• Behaviorally \_\_\_\_
• Hyperactive gag reflex
• Those undergoing an \_\_\_\_ or extensive procedure

anxious
challenged
invasive

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Mortality rates
• Range from 7.9 per 10,000 to 1 per 400,000
anesthetic cases
This is something that is ____
• 65 to 87% of them is due to ____ error
• The most common problem is failure to ____ a
patient

correctable
human
ventilate

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From 1988 to 2004, performed 29.6 million
40 deaths, 2 brain dead
1:7____

700,000

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Continuum of Consciousness
• when you think of sedation you want to think of it on an continuum of ____
• On this end, it’s going to be the ____ patient, totally conscious
• And on the other end, general anesthesia, the patient with be completely
____

consciousness
awake
unconscious

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Levels of Sedation
• Minimal sedation is equivalent to ____, that is, a ____- induced relief of apprehension with ____ effect on sensorium.

Moderate sedation is a depression of consciousness in which the patient can ____ to external stimuli (verbal or tactile). Airway reflexes, spontaneous ventilation, and cardiovascular function are ____.
Deep sedation is a depression of consciousness in which the patient ____ be aroused but responds purposefully to repeated or painful stimuli. The patient may not be able to maintain ____ reflexes or spontaneous ventilation, but ____ function is preserved.
General anesthesia is a state of ____; the autonomic nervous system is ____ to respond to surgical or procedural stimuli.

anxiolysis
drug
minimal

respond
maintained

cannot
airway
cardiovascular

unconsciousness
unable

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Assessment by Observation
• Fully \_\_\_\_
• Drowsy
• Response to \_\_\_\_ 
• Response to touch 
• Response to \_\_\_\_ 
• No response

awake
voice
pain

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Routes of Administration
• \_\_\_\_
• Inhalation
• \_\_\_\_
• Intramuscular 
• \_\_\_\_
• Submucosal
• \_\_\_\_
• Subcutaneous 
• \_\_\_\_
• Intraosseous

oral
intravenous
rectal
intranasal
transdermal

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Oral Sedation:
Benefits
▪ Easy to \_\_\_\_
▪ Provides \_\_\_\_ relief 
▪ \_\_\_\_ to use

administer
anxiety
safe

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Oral Sedation:
Limitations
• \_\_\_\_ onset of drug action
• Less effective when compared with \_\_\_\_
administration
• Inability to \_\_\_\_ the dose
• \_\_\_\_ to administer reversal agent

delayed
parenteral
titrate
difficult

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Inhalation Sedation:
Advantages
• Onset of action is more ____ than oral, rectal and intramuscular sedation
• Depth of sedation may be ____ from moment to moment
• ____ recovery time
• No ____ is required
• ____

rapid
altered
rapid
injection
safe

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Inhalation Sedation:
Disadvantages
• \_\_\_\_
• Space requirements • Not \_\_\_\_
• Requires cooperation

cost

potent

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Sedation Methods:
Inhalation Sedation

Nitrous oxide
Most ____
Light conscious sedation
Decreases ____ and anxiety
Analgesic properties
Can be used in ____ or solo

common
fear
combo

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Intravenous Sedation
• NPO (nothing to eat or drink after ____ the night before the procedure)
• ____ to accompany patient after the procedure
• History and physical ____

midnight
escort
examination

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Monitoring
• Patient must be ____ at all times
• A comprehensive ____ must be kept
• All patients must have a ____ and physical and baseline vitals

watched
record
history

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Monitoring:
Parameters
• \_\_\_\_ • Ventilation
• \_\_\_\_
• Temperature

oxygenation

circulation

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Standards for Basic Anesthetic Monitoring
• Standard I: Qualified anesthesia personnel shall be ____ in the room throughout the conduct of all general anesthetics, regional anesthetics, and monitored anesthesia care.

• Standard II: During all anesthetics, the patient’s ____, ventilation, circulation, and ____ shall be continually evaluated.

present
oxygenation
temperature

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Goals of Monitoring
• Improves patient outcome by allowing early recognition of potentially ____complications
• Aids in the ____ of anesthesia administration

life-threatening

anesthesia

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Emergency Equipment
• \_\_\_\_ source
• Ambu bag and mask
• \_\_\_\_
• Oral and nasal airways
• \_\_\_\_ blade and handles 
• Endotracheal tubes and stylet
• \_\_\_\_ mask airways

oxygen
suction
laryngoscope
laryngeal

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Emergency Equipment
• Drugs
• \_\_\_\_
• Flumazenil
• \_\_\_\_ 
• Epinephrine
• \_\_\_\_
• Vasopressin
• \_\_\_\_
• ASA

____ Given when HR below 40 - not typically given in emergency situation
Glucose For hypoglycemic patient, if diabetic patient has taken insulin without eating
____ For allergic reaction
Diazepam or midazolam For breaking seizures
____, methylprednisolone, or dexamethasone ◦Also for allergic reactions

naloxone
succinylcholine
amiodarone
nitroglycerin

atropine
diphenhydramine
hydrocortisone

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Anesthesia Record

No specific ____
Record must be neat, concise and coherent
Should document the patients ____, the preanesthetic evaluation of the patient, the ____ events, postanesthetic condition of the patient

format
demographics
intraoperative

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Intravenous Sedation:
Medications
• \_\_\_\_
• Opioids
• \_\_\_\_ Don’t really use these for sedation because they have too many AE
• \_\_\_\_ 
• Ketamine

benzodiazepines
antihistamines
propofol

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Anxiolytics and Sedative-Hypnotics
• ____
Barbiturates
• ____

benzodiazepines

antihistamines

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Benzodiazepines
• \_\_\_\_ (Versed)
• Diazepam (Valium)
• \_\_\_\_ (Ativan)
• Triazolam (Halcion)
• \_\_\_\_ (Restoril)
• Alprazolam (Xanax)

• ____ is our drug of choice
• Triazolam is the drug she spoke about earlier
◦It’s the short acting drug that was given in incremental doses and patients were dying from it
• ____ is a sleep agent
◦It is given to patients in the hospital as needed for sleep after
surgery
• ____ is a shorter acting benzodiazepines
• lorazepam and alprazolam are miming(?) drug that she would use for
an oral sedation cause they are shorter acting and don’t have active
metabolites
• And again midazolam is our drug of for IV sedation procedures

midazolam
lorazepam
temazepam

midazolam
temazepam
xanax

Benzodiazepines:
Effects
• \_\_\_\_
• Sedation
• \_\_\_\_
• Anticonvulsant
• \_\_\_\_ excitation 
• \_\_\_\_ cardiovascular
  and respiratory effects

anxiolysis
amnesia
parodoxical
minimal

Benzodiazepines: Pharmacodynamics * Bind to ____ receptors and alter configuration of ____ * Allow for a greater influx of ____ into cell

BZ GABA chloride

``` Benzodiazepines: Metabolism • Metabolized by ____ • Metabolites are then conjugated primarily with ____ • Excreted via ____ ```

liver glucuronic acid kidneys

Diazepam (Valium) • ____administration • ____ administration can cause thrombophlebitis • ____ elimination half-life (nordazepam)

oral and parenteral IV prolonged

``` Midazolam (Versed) • Oral and ____ • More ____ Than diazepam • Peak plasma levels in ____ • ____ half-life This is because there is no active metabolites that exert its effect well after the post op period • No ____ metabolites • More reliable ____ effect This is a very important property for ambulatory anesthesia because we don’t want our patients remembering the event. ```

``` parenteral potent 30 to 60 min shorter active amnestic ```

Flumazenil (Romazicon) • Benzodiazepine ____ • ____ agent • ____ administration in ____ mg increments up to ____ mg

``` antagnoist reversal IV 0.2 1 ```

``` Barbiturates • Deep ____ or general anesthesia (thiopental and methohexital) • ____ (phenobarbital) • Can induce paradoxical ____ • ____ therapeutic dosage range • No ____ agent ```

``` sedation anticonvulsants excitement limited reversal ```

Antihistamines * ____ * Preoperative anxiety * Anti-____ * Antagonists at histaminergic, cholinergic, and dopaminergic receptor sites * ____ (Vistaril), Promethazine (Phenergan)

insomnia emetics hydroxyzine

Opioids •Opioid includes both ____ opiates and opiate like drugs •Classified by ____ structure or ____ on opioid receptors

true chemical action

``` ◦ The agonist ‣ ____ ‣ Codeine ‣ ____ ‣ Hydrocodone ‣ Dilaudid ‣ These will be the top five opioids we would use • These are just general ``` ``` • For sedation we would use: ◦ ____ ◦ Alfentanil ◦ ____ ◦ Remifentanil ◦ These are all synthetic opioids ◦ The opioids listed below fentanyl are stronger derivatives of fentanyl ``` • Antagonist we will use ____ or Narcan • We don’t really used the mixed agonist/antagonist ◦They are used for obstetrics and other types of procedures

morphine oxycodone fentanyl sulfentanil naloxone

``` Pharmacokinetics • Significant ____ effect • Metabolized in liver via ____ • Metabolites are generally ____ • Metabolites are excreted by the ____ ```

first pass glucoronidation inactive kidneys

Pharmacodynamics * Opioid Receptors * ____ * kappa * ____ * Widely ____ throughout CNS * Found in ____ tissues

mu delta distributed peripheral

``` Indications • Adjuncts in ____ and general anesthesia • Postoperative ____ Primarily purepose of this drug is analgesia • ____ Dextromethorphan can be used to treat cough, but that’s not something we use during an anesthesia procedure • ____ ```

sedation analgesia cough detoxification

Opioid Effects: Analgesia • Increase pain ____ and tolerance • Inhibit ____ release from synapses of the ____ ganglia • Inhibit ____ fiber stimulation and ____ fiber stimulation

``` threshold substance P dorsal root C A delta ```

Opioid Effects: Sedation • Induce ____ and decreased awareness • Take caution when combining with other ____ depressants

drowsiness | CNS

Opioid Effects: Mood Alteration • ____ • Dysphoria

euphoria

Opioid Effects: Respiratory Depression • Dose-dependent ____ in response to carbon dioxide in respiratory center • ____ respiratory rate, ____ tidal volume • Beware with patients with ____ and the ____

``` decrease decreased increased COPD elderly ```

Opioid Effects: Tolerance • ____ response to the same dose of a drug after repeated administration

decreased

Opioid Effects: Physical Dependence • ____ symptoms followed by abrupt cessation of the drug • Symptoms include ____, rhinorrhea, ____, yawning, myalgia, hyperventilation, hyperthermia, ____, vomiting, diarrhea, ____, hostility

``` withdrawal pilo-erection lacrimation mydriasis anxiety ```

Opioid Effects: Addiction • A ____ to continue using a substance despite a lack of medical ____

compulsion | necessity

Opioid Effects: Antitussive Effect • Depress ____ reflex • Dextroisomers (____)

cough | dextromethorphan

``` Opioid Effects: GI system • ____ and vomiting • Constipation • ____ ```

nausea | biliary spasm

``` Opioid Effects: Other • ____ release • ____ • Chest wall ____ • Neuroendocrine effects ```

histamine miosis rigidity

Morphine • ____ lipid solubility • Delayed onset and long duration of action • Minimal ____ effects • Can increase smooth muscle tone • Can cause ____ release • Can lead to increased intracranial pressure (ICP) • Used for postoperative ____ and for chronic severe pain

poor cardiovascular histamine pain

Meperidine (Demerol) • ____ • ____ duration of action • Greater ____ solubility • Cardiovascular effects • Metabolite ____ has been associated with toxicity • Contraindicated in patients taking ____

``` synthetic shorter lipid normeperidine MAOIs ```

``` Fentanyl • ____ • 75 to 125 times more potent than ____ • ____ onset • ____ duration of action • High ____ solubility • High ____ effect • No ____ release • Contraindicated in patients taking ____ • ____, Sufentanil, and Remifentanil ```

``` synthetic morphine rapid short lipid first pass histamine MAOIs alfafentanil ```

◦But look how long it takes morphine to reach peak analgesic effect, ____ minutes, we don’t have that time to wait plus it will last ____ hour ◦Fentanyl reaches peak effect in ____ minutes and only last ____ minutes similar to Midazolam

20 4-5 3-5 30-60

``` Opioid Agonist/Antagonists • Agonist and antagonist effects on receptors • Lack efficacy of ____ agonists • ____ effects on respiratory depression • ____ (Talwin) • Nalbuphine (Nubain) • ____ (Stadol) ```

pure ceiling pentazocine butorphanol

``` Opioid Antagonists: Naloxone (Narcan) • ____ agent • Onset of action is ____ min ____ • Titrated ____ to effect • Must ____ closely ```

``` reversal 1 to 2 IV slowly monitor ```

Clinical Considerations • Decrease doses in ____, renal or ____ compromise • ____ • ____-dependent patients

elderly hepatic allergy opioid

``` Propofol • Appears as ____ oil in water emulsion • Cardiorespiratory effects • Elimination half-life ____ hours • ____ distributed to tissues • ____ onset • ____ recovery • ____ effects • Does not cause ____ • No ____ effect ```

``` white 2 to 24 rapidly short quick amnestic nausea analgesic ```

``` Ketamine • Non-competitive ____-antagonist • Derivative of the hallucinogen ____ • Produces deep dissociative ____, analgesia, and ____ • ____ ```

``` NMDA phencyclidine sedation amnesia IV and IM ```

Ketamine • Highly ____ soluble • Short onset • ____ elimination half-life • Bronchodialation Respiration will approve on this — ideal for asthmatics • Preserves ability to ____ spontaneously • Protective reflexes remain intact • Increase airway ____ Makes it difficult to suture - may have to give an antisialagogue • Stimulatory effect on ____ system • Random ____ are common

``` lipid short breathe secretions cardiovascular movements ```

``` Guidelines for discharge • Patients should be ____ and oriented • ____ signs should be stable • ____ time should have elapsed after the last administration of reversal agent • ____ • ____ instructions ```

``` alert vital sufficient escort written ```