4. Ambulatory Anesthesia Flashcards
Potential Candidates • \_\_\_\_ or fearful • Young children • Behaviorally \_\_\_\_ • Hyperactive gag reflex • Those undergoing an \_\_\_\_ or extensive procedure
anxious
challenged
invasive
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
- From 1988 to 2004, performed 29.6 million
- 40 deaths, 2 brain dead
- 1:7____
700,000
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
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
Assessment by Observation • Fully \_\_\_\_ • Drowsy • Response to \_\_\_\_ • Response to touch • Response to \_\_\_\_ • No response
awake
voice
pain
Routes of Administration • \_\_\_\_ • Inhalation • \_\_\_\_ • Intramuscular • \_\_\_\_ • Submucosal • \_\_\_\_ • Subcutaneous • \_\_\_\_ • Intraosseous
oral intravenous rectal intranasal transdermal
Oral Sedation: Benefits ▪ Easy to \_\_\_\_ ▪ Provides \_\_\_\_ relief ▪ \_\_\_\_ to use
administer
anxiety
safe
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
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
Inhalation Sedation: Disadvantages • \_\_\_\_ • Space requirements • Not \_\_\_\_ • Requires cooperation
cost
potent
Sedation Methods:
Inhalation Sedation
- Nitrous oxide
- Most ____
- Light conscious sedation
- Decreases ____ and anxiety
- Analgesic properties
- Can be used in ____ or solo
common
fear
combo
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
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
Monitoring: Parameters • \_\_\_\_ • Ventilation • \_\_\_\_ • Temperature
oxygenation
circulation
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
Goals of Monitoring
• Improves patient outcome by allowing early recognition of potentially ____complications
• Aids in the ____ of anesthesia administration
life-threatening
anesthesia
Emergency Equipment • \_\_\_\_ source • Ambu bag and mask • \_\_\_\_ • Oral and nasal airways • \_\_\_\_ blade and handles • Endotracheal tubes and stylet • \_\_\_\_ mask airways
oxygen
suction
laryngoscope
laryngeal
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
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
Intravenous Sedation: Medications • \_\_\_\_ • Opioids • \_\_\_\_ Don’t really use these for sedation because they have too many AE • \_\_\_\_ • Ketamine
benzodiazepines
antihistamines
propofol
Anxiolytics and Sedative-Hypnotics
• ____
Barbiturates
• ____
benzodiazepines
antihistamines
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
