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Anesthesia Agents/ Adjuncts/ Reversal Flashcards

1
Q

What is ASA Score?

A

Rates physical status of patient assessed prior to receiving sedation/ anesthesia.

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2
Q

All about ASA

What are the different ASA Scores/ levels?

A

ASA 1 Healthy Pt
ASA 2 Healthy Pt with mild systemic disease (BMI>30)
ASA 3 Pt with severe systemic disease that limits activity
but not incapacitating (BMI>40)
ASA 4 Pt with severe systemic disease that is constant
threat to life

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3
Q

What are the different ASA Scores/ levels?

A

ASA 5 Pt not expected to survive without urgency
ASA 6 Pt brain dead to OR for organ harvest
ASA E Any emergency surgical procedure

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4
Q

What are examples of ASA 2?

A

Mild diseases only without substantive functional limitations. Current smoker, social alcohol drinker, pregnancy, obesity (30<BMI<40), well-controlled DM/HTN, mild lung disease

https://www.asahq.org/standards-and-practice-parameters/statement-on-asa-physical-status-classification-system

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5
Q

What are examples of ASA 3?

A

Substantive functional limitations; One or more moderate to severe diseases. Poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, history (>3 months) of MI, CVA, TIA, or CAD/stents.

https://www.asahq.org/standards-and-practice-parameters/statement-on-asa-physical-status-classification-system

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6
Q

What are examples of ASA 4?

A

Recent (<3 months) MI, CVA, TIA or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, shock, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis

https://www.asahq.org/standards-and-practice-parameters/statement-on-asa-physical-status-classification-system

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7
Q

What is general anesthesia?

A

State of reversible unconsciousness where protective reflexes are partially or completely lost.

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8
Q

What is monitored anesthesia care?

A

Relaxed, **non-paralyzed state **of analgesia and sedation
Pt maintains airway independently
Responds to verbal commands
!Administered by anesthesiologist/ CRNA

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9
Q

What is the 1st stage of anesthesia?

A

BEGINS with initiation and
ENDS with loss of consciousness

Protective reflexes maintained
!Patient feels conscious but drowsy
!Patient can follow simple commands
!Perception of pain is diminished

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10
Q

What is the 2nd stage of anesthesia?

A

BEGINS with loss of consciousness and
ENDS with loss of protective reflex

!Delirium/ Excitation (highest risk stage)
!Breath holding
!Dilated pupils
!Irregular respirations
Muscle tone intact

Vomiting, laryngospasm, cardiac arrest can happen.

Odom-Forren J. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders; 2013: 255)

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11
Q

What is the 3rd stage of anesthesia?

A

BEGINS with regular breathing pattern and ENDS with respiratory cessation

Absent protective reflexes
No eyelash response nor lid reflex
No spontaneous respiration
No response to surgical incision
Surgery occurs during this stage

Also referred to as surgical anesthesia.

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12
Q

What is the 4th stage of anesthesia?

A

Medullary depression
Depression of vital functions
Respiratory cessation
Cardiac / circulatory collapse

Also referred to as overdose (coding stage)

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13
Q

What is the order of anesthesia induction?

A
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14
Q

How does emergence from anesthesia occur?

A

!Reverse order of induction
Anesthesia agents titrated off
Influenced by
* Duration of anesthesia
* Use of other drugs
* Physical status of patient

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15
Q

What is the patient at risk for during the anesthesia stage of delirium?

A

Vomiting
Laryngospasm
Cardiac arrest

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16
Q

What is Glasgow Comma Scale?

A

GCS score range
15: Normal level of consciousness
14–15: Mild traumatic brain injury (TBI)
9–13: Moderate TBI
3–8: Severe TBI
3: Vegetative state or brain death

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17
Q

Where is the HIGH blood flow area for volatile & gaseous inhalation agents?

A

Kidney
Liver
Brain
Heart
Endocrine glands

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18
Q

Where is the MODERATE blood flow area for volatile & gaseous inhalation agents?

A

Muscle
Skin

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19
Q

Where is the POOR blood flow area for volatile & gaseous inhalation agents?

A

Fat
Bone marrow
Avascular tissue

The greater the fat the longer it takes to eliminate anesthesia.

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20
Q

Part of body with slowest elimination of volatile & gaseous inhalation agents

A

!Fat group - serves as area for anesthesia to linger. Thus more fat takes longer to eliminate anesthesia.

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21
Q

Why is SEVOFLURANE ( volatile & gaseous inhalation agent) good for induction and pediatrics?

A

!Pleasant, non irritating odor

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22
Q

What are safety profiles of SEVOFLURANE ( volatile & gaseous inhalation agent)?

A

Does not sensitize myocardium
No effect on hepatic blood flow
Safe for pts with seizure disorder
(d/t minimal increase ICP)

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23
Q

Volatile & gaseous inhalation agent

What are precautions for SEVOFLURANE?

A

!Potentiates neuromuscular blockade

Neuromuscolar blockers are either depolarizing or non-depolarizing.

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24
Q

Volatile & gaseous inhalation agent

How is SEVOFLURANE degraded?

A

!Degraded through exposure with soda lime*

*granular mixture of (Ca(OH)2), (NaOH) or (KOH), to absorb co2+moisture

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25
Q

Volatile & gaseous inhalation agent

Why is HALOTHANE good for induction and pediatrics?

A

!Pleasant non-irritating odor
Commonly used in pediatrics

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26
Q

Volatile & gaseous inhalation agent

What are precautions for HALOTHANE?

A

Can cause:
!Increased ICP
Myocardial depression
Impaired AV node function
Halothane hepatitis

Remember that Sevoflurane does not cause any of these.

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27
Q

Volatile & gaseous inhalation agent

How is HALOTHANE metabolized and excreted?

A

Metabolized in liver
Excreted 80% lungs, 20% kidneys

Remember halothane hepatitis.

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28
Q

Volatile & gaseous inhalation agent

Why is ISOFLURANE only used as maintenance anesthesia?

A

Pungent, irritating odor

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29
Q

Volatile & gaseous inhalation agent

What is the benefit of administering ISOFLURANE?

A

Increases coronary blood flow

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30
Q

Volatile & gaseous inhalation agent

What are **precautions **for ISOFLURANE?

A

Causes vasodilation - post operative shivering
Potentiates neuromuscular blockade

Neuromuscular blockers can either be depolarizing or non-depolarizing

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31
Q

Volatile & gaseous inhalation agent

How is ISOFLURANE metabolized and excreted?

A

Eliminated by exhalation
Excreted by kidneys

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32
Q

Volatile & gaseous inhalation agent

Why is DESFLURANE used as maintenance anesthesia only?

A

Pungent, irritating odor

Same as isoflurane

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33
Q

Volatile & gaseous inhalation agent

What is the advantage of administering DESFLURANE?

A

!Rapid onset and offset due to extremely low solubility in blood

Good for rapid anesthesia induction and emergence like obese and elderly

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34
Q

Volatile & gaseous inhalation agent

What are precautions for DESFLURANE?

A

Causes vasodilation - post operative shivering
Potentiates neuromuscular blockade
(same as isoflurane)

Neuromuscular blockers can be depolarizing or non-depolarizing

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35
Q

Volatile & gaseous inhalation agent

How is DESFLURANE metabolized and excreted?

A

Eliminated through exhalation

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36
Q

Anesthesia induction agents

What are the different categories of anesthesia induction agents?

A

Sedative & hypnotic agents
Dissociative agents
Alpha2 agonists
Benzodiazapines

Alpha2 adrenergic receptors bind to cathecolamine during body’s stress

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37
Q

Anesthesia induction agents

What is an anesthesia induction agent?

A

Administered to induce anesthesia so anesthesia is initiated easily without residual effects.

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38
Q

Anesthesia induction agents

What kind of anesthesia induction agent is thiopental?

A

Ultra short acting CNS depressant that induces hypnosis and anesthesia, but not analgesia

Same as edomidate, does not provide analgesia

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39
Q

Anesthesia induction agents

What are the nursing precautions for anesthesia induction agent thiopental?

A

Can lower BP (use less dose if with cardiac issue)
Do not use if with sulfa allergy
Caution with liver patients

Garlic taste. Patient may experience hangover effect.

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40
Q

Anesthesia induction agents

What kind of anesthesia induction agent is methohexital sodium?

A

Barbiturate - acts as CNS depressant
MOA - inhibit neurotransmitter GABA leading to calming/ sedative effect

Phenobarbital, a barbiturate (for seizure, treat anxiety or drowsiness)

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41
Q

Anesthesia induction agents

What are the nursing assessments for anesthesia induction agent methohexital?

A

Hiccup
Cardiovascular depression
Respiratory depression and apnea

Prepare for ventilation support, if needed

42
Q

Anesthesia induction agents

What is kind of anesthesia induction agent is etomidate?

A

Hypnotic only, no analgesic
non-barbiturate

43
Q

Anesthesia induction agents

Why is anesthesia induction agent etomidate preferred for patients with cardiovascular disease?

A

Etomidate less likely to cause hypotension and with mimimal inotropic effects.

44
Q

Anesthesia induction agents

What is common side effect for anesthesia induction agent etomidate?

A

Nausea and vomitting

45
Q

Anesthesia induction agents

What is important to know about anesthesia induction agent etomidate?

A

Pain in IV site upon injection
May cause temporary adrenal insufficiency*
(Do not use in critically ill patients)

*Adrenal glands produce less cortisol and aldosterone.

46
Q

Anesthesia induction agents

What is important to know about anesthesia induction agent propofol?

A

!Fat based
!Contraindicated with patients with sensitivity to soybean oil, egg, lecithin, glycerol
Administered with lidocaine on injection site d/t pain

47
Q

Anesthesia Agents/ Adjuncts/ Reversal

What to watch out for about anesthesia induction agent propofol?

A

Propofol decreases blood pressure, cardiac output, and systemic vascular resistence. Elderly patients more susceptible. Pulse remains unchange due to sympatholytic or vagotonic effect.

Odom-Forren J. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders; 2013:267.

48
Q

Anesthesia induction agents

What is kind of anesthesia induction agent is ketamine?

A

Dissociative anesthesia

49
Q

Anesthesia induction agents

What is the side effect of anesthesia induction agent ketamine?

A

Hallucination
Potential for abuse

50
Q

Anesthesia Agents/ Adjuncts/ Reversal

How does anesthesia inducation agent ketamine affect the respiratory system?

A

Respiration function unimpaired but rapid iv injection can depress respiration temporarily
Pharyngeal and laryngeal reflexes remain intact

Odom-Forren J. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders; 2013:274-276.

51
Q

Anesthesia Agents/ Adjuncts/ Reversal

How does anesthesia inducation agent ketamine affect the neurological system?

A

Increased cerebral blood flow and inctracranial pressure

Odom-Forren J. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders; 2013:274-276.

52
Q

Anesthesia Agents/ Adjuncts/ Reversal

How does anesthesia inducation agent ketamine affect the cardiovascular system?

A

Moderate accelaration of heart rate with temporary increase of pulse and blood pressure

Odom-Forren J. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders; 2013:274-276.

53
Q

Anesthesia induction agents

How to reduce dissociative phenomena of anesthesia induction agent ketamine?

A

Request benzo for pre/post op to provide sedation
Discuss possible vivid dreams/ hallucination to patient

54
Q

What kind of anesthesia induction agent is clonidine?

A

alpha2 agonist
provides sedation and analgesia without respiratory depression

55
Q

What are the side effects of anesthesia induction agent clonidine?

A

Dry mouth
Sedation
Bradycardia
Contact Dermatitis

56
Q

What kind of anesthesia induction agent is dexmedetomidine?

A

alpha2 agonist
provides sedation and analgesia without respiratory depression

57
Q

What are the side effects of anesthesia induction agent is dexmedetomidine?

A

Bradycardia and hypotension because it potentiates effect of opioids, sedatives and hypnotics, anesthetics, and other vasoactive agents

58
Q

What kind of anesthesia induction agent is midazolam?

A

Benzodiazapine - producing hypnotic effect, retrograde amnesia, anxiolysis and skeletal muscle relaxation

59
Q

Anesthesia Agents/ Adjuncts/ Reversal

What are the side effects of anesthesia induction agent midazolam?

A

Decrease blood pressure
Increase heart rate
Decrease SVR

Caution with myocardial ischemia because it increases cardiac workload

Odom-Forren J. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders; 2013:269.

60
Q

Anesthesia Agents/ Adjuncts/ Reversal

What is the reversal medication for anesthesia induction agent midazolam?

A

Oversedation - treated by Flumazenil 0.2mg IV over 15 seconds, repeated Q 1 minute, with maximum dose of 1mg

61
Q

What are anesthesia adjuncts?

A

Administered to enhance anesthesia but not considered anesthetics. May serve to reduce anxiety, sedate patient, reduce oral/ respiratory secretions.

62
Q

What is droperidol (anesthesia adjunct)?

A

Antiemetic

63
Q

What is dexmedetomidine (anesthesia adjunct)?

A

Non-opioid IV anesthetic
Controls stress, anxiety, and pain but no respiratory depression

64
Q

What is the important characteristic of muscle relaxants?

A

!Do not cross blood brain barrier

65
Q

Why are muscle relaxants needed?

A

To relax jaw and larynx during intubation
To relax skeletal muscle for surgery

66
Q

What prolongs the action of muscle relaxants?

A

Hypothermia

67
Q

What is the sequence of PARALYSIS for muscle relaxants?

A

Fine motor -> Gross motor
Eyes > Jaw > Hands > Limbs > Neck > Intercoastal Muscle > Diaphragm

68
Q

What is the sequence of RECOVERY for muscle relaxants?

A

Reverse of paralysis
Diaphragm > Intercoastal Muscle > Neck > Limbs > Hands > Jaw > Eyes

69
Q

What is succinylcholine (depolarizing muscle relaxant)?

A

!Causes muscle to contract by binding to muscle cell receptor sites, competes with acetylcholine
!Succinylcholine binds longer than acetylcholine
Ultra short acting (5-10 min)
Antinicotinic medication

70
Q

What are the effects of succinylcholine (depolarizing muscle relaxant)?

A

!Fasciculations
!Myalgia
Can stimulate vagal nerve - bradycardia
Mild histamine release - rashes on arms/ chest
Increase ICP
Increased release of k+ to extracellular fluid

71
Q

Anesthesia Agents/ Adjuncts/ Reversal

During preoperative assessment, patient reports “I don’t react well to anesthesia. The last time I had surgery, I had horrible muscle pain in my neck and back next day. It even hurts to blink my eyes and smile.” The nurse suspects this discomfort was due to:
a. surgical positioning
b. ketamine
c. succinylcholine
d. rocuronium

A

Succinylcholine casues fasciculations or mini contractions as the muscle cell depolarizes after drug administration. These fasciculations frequently lead to muscle pain.

Odom-Forren J. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders; 2013:300.

72
Q

What is “defasciculation”?

A

Administration of non depolarizing muscle relaxant prior to succinylcholine to prevent muscle twitch/ fasciculation.

73
Q

29 y/o male admitted s/p fasciotomy for bilateral crush injuries of legs experiences partial laryngospasm when extubated. While preparing to intubate, anesthesia ask RN to administer succinylcholine 20mg IV. The RN shoud:

  1. refuse to administer medication
  2. request anesthesiologist to repeat dosage
  3. dilute drug with 10cc NS before administration
  4. titrate drug over 3 minutes
A

Refuse to administer medication because bilateral crush injuries can cause life threatening level of potassium release which is one of the contraindications of administering succinylcholine.

74
Q

How is succinylcholine (depolarizing muscle relaxant) eliminated in the body?

A

Broken down by plasma cholinesterase aka pseudocholinesterase

75
Q

Which part of the body produces pseudocholinesterase (depolarizing muscle relaxant)?

A

Produced by the liver
Pseudocholinesterase level directly related to albumin level

76
Q

Who can have pseudocholinesterase (depolarizing muscle relaxant) deficiency?

A

Inherited
Advanced age, renal failure, malnutrition, hepatic disease

77
Q

What is the effect of pseudocholinesterase deficiency (depolarizing muscle relaxant)?

A

!Prolonged paralysis that can lead to ventilation in PACU
!Tincture of time

78
Q

Patient had recent (past 2-4 days) neuromuscular injury. Why can’t patient receive succinylcholine (depolarizing muscle relaxant)?

A

Can cause life threatening levels of K+ release
(e.eg. major burns, multiple trauma, CVA, denervation of muscles, recent spinal cord injury - within 6 months)

79
Q

Patient has chronic illness. Why can’t patient receive succinylcholine (depolarizing muscle relaxant)?

A

Risk for hyperkalemia
(e.g. prolonged immobilization, atrophy, critically ill)

80
Q

Other medical conditions when patient can not be administered with succinylcholine (depolarizing muscle relaxant)?

A

Children with muscular dystrophies
!History or family history of malignant hypothermia because succinylcholine can trigger MH

81
Q

Patient developed respiratory failure and required intubation. Succinylcholine IV to be administered as part of rapid sequence intubation. Perianesthesia RN knows to have which drug ready to counteract fasciculations?

  1. benzodiazaphines
  2. non-depolarizing muscle relaxants
  3. antihistamines
  4. sustained released anticonvulsants
A

non-depolarizing muscle relaxants

82
Q

What are non-depolarizing muscle relaxants?

A

Blocks acetylcholine from binding to muscle receptor sites. Thus muscle is unable to contract.

83
Q

What medications enhance NDMR paralysis?

A

Aminoglycosides
! Calcium Channel Blockers
Clindamycin
Lithium
Magnesium
Tetracycline
Volatile anesthetics

84
Q

Anesthesia Agents/ Adjuncts/ Reversal

What physiological factors enhance NDMR paralysis?

A

Respiratory Acidosis
Hypothermia
Dehydration
HYPERcapnia
Hypokalemia
Hyponatremia
HYPERmagnesemia

85
Q

What are considered NDMR antagonists?

A

Caffeine Hypocapnia
Reversal agents HYPERkalemia
Epinephrine HYPERnatremia
Norepinephrine Respiratory Akalosis
Theophylline

86
Q

Name the long acting NDMRs?

A

!Tubocurarine
!Doxacurium
!Pancuronium
!Pipecuronium

87
Q

What are NDMR reversal agents?

A

!Anticholinesterase agents - inhibit breakdown of acetylcholine

88
Q

What are common NDMR reversal agents?

A

!Sugammadex - reverses rocuronium and vecuronium
Neostigmine - must be given with glycopyrrolate
Edrophonium - must be given with atropine
Pyridostigmine - given with glycopyrrolate

89
Q

What to watch out for in administering Sugammadex (NDMR reversal agent)?

A

!Decreases serum concentration of estrogen and progestin derivatives

90
Q

What is the mechanism of action for neostigmine (NDMR reversal agent)?

A

Neostigmine binds to acetylcholinesterase (anticholinesterase) thus increases the number of acetylcholine

91
Q

What is the mechanism of action for Sugammadex (NDMR reversal agent)?

A

Sugammadex binds to NDMR, thus acetylcholine can occupy receptor sites

92
Q

Why atropine or glycopyrrolate is administered with the NDMR reversal agent?

A

Neostigmine is cholinergic that cause muscarinic side effects such as bradycardia.
Atropine and glycopyrrolate are anticholinergics that maintain stable heart rhythm.

93
Q

Patient reversed with endrophonium and atropine. The reason for atropine administration is:

  1. decrease likelihood of vomiting
  2. promote acetylcholine release
  3. enhance onset of nueromuscular reversal
  4. minimize muscarinic stimulation
A

minimize muscarinic stimulation

94
Q

Residual paralysis is a complication of what type of medication?

A

Non depolarizing muscle relaxants

95
Q

What is residual paralysis (in NDMR)?

A

Reversal agent wears off before the breakdown of NDMR
!common sign fish mouth breathing

96
Q

What type of medication is glycopyrrolate?

A

Anticholinergic
A quaternary amine used in anesthesia to decrease salivary and tracheal secretions, per National Library of Medicine

97
Q

Why is glycopyrrolate given with neostigmine?

A

Neostigmine binds to acetylcholinesterase, thus increases the number of acetylcholine and reverses NDMR agent. Neostigmine is cholinergic with s/e bradycardia and bronchospasm. Glycopyrrolate is anticholinergic.

98
Q

What are the side effects of anti cholinergucs?

A

dry mouth, blurred vision, increased heart rate, constipation, and urinary retention

99
Q

What are the advantages of glycopyrrolate over atropine?

A

Works for a longer time and requires less amount of medication. Atropine can also cause delirium and confusion.

100
Q

What is nitrous oxide?

A

Odorless, sweet smelling gas that is not potent to provide anesthesia

101
Q

What is nursing concern for nitrous oxide?

A

High concentration can cause hypoxia. Therefor administer with O2.

102
Q

How is nitrous oxide metabolized?

A

Diffusion, until it eventually equilibrates out

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