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Anesthesia (Strauss) Flashcards

0
Q

What is the benefit of inhalation anesthesia over IV drugs?

A

Easier to use and titrate patient

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1
Q

What is the term for the use of a gaseous agent to achieve anesthesia from sedation to general anesthesia?

A

Inhalation anesthesia

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2
Q

Inhalational anesthesia is generally used for general anesthesia, except for which inhalant?

A

NO (Nitrous oxide?)

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3
Q

What is the state of current inhalational drugs?

A

Volatile liquids, not gases, that are non-flammable and non-explosive

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4
Q

All current inhalant drugs work on what system?

A

Reticular activating system

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5
Q

What is an instrument that adjusts flow to match output of the inhalant, accounts for temperature, and is specific to the agent?

A

Vaporizer

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6
Q

What are 4 methods to administer inhalants?

A
  1. Nasal Hood
  2. Full face mask
  3. LMA (laryngeal mask anesthetic)
  4. Endotracheal intubation
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7
Q

What is the method to administer inhalant indicated for oral procedures?

A

Nasal hood

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8
Q

What is the method to administer inhalant indicated for short procedures outside the face?

A

Full face mask

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9
Q

What are 2 methods to administer inhalant indicated for longer procedures?

A
  1. Laryngeal Mask anesthetic (LMA)

2. Endotracheal intubation

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10
Q

What are the 3 levels of respiration for the patient when on inhalational anesthesia?

A
  1. Spontaneously
  2. Assisted
  3. Controlled
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11
Q

What is the level of respiration for ambulatory procedure using inhalational anesthesia?

A

Spontaneous respiration

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12
Q

Why would a patient on an inhalational require aide with respiration?

A

Because all inhalationals are respiratory depressants (they also slow the heart rate a bit)

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13
Q

Therapeutic ratio is the difference between the therapeutic effect and toxicity, a lower ratio means what?

A

The lower the ration, the more dangerous the drug

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14
Q

Which part of respiration is active: inhalation or exhalation?

A

Inhalation

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15
Q

What is the reason for a patient needing assisted ventilation when on inhalational anesthesia?

A

Decreased tidal volume and rate

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16
Q

A nasal hood is easy to use and allows oral access, but what are its disadvantages?

A
  1. No positive pressure available
  2. No airway protection
  3. Difficult to control how much patient gets
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17
Q

A full face mask allows for a good seal, positive pressure ventilation, and 100% gas intake with no mixing, but what are the disadvantages?

A

No airway protection, no mouth access

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18
Q

What are some advantages of inhalational anesthesia?

A
  1. Easy to use
  2. Easily controllable/titratable
  3. Predictable effects
  4. Low toxicity
  5. Rapid effect
  6. Continuous dosing so very stable
  7. Can always add IV drug as needed
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19
Q

A full face mask is good for what part of the procedure?

A

Induction or non-oral procedures

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20
Q

What instrument gives partial airway protection, is easier to place in a difficult airway, and allows for better airway maintenance?

A

Laryngeal mask anesthetic (LMA)

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21
Q

All airway tubes have what at the connector end?

A

Universal 15mm connector at the end

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22
Q

On what does the LMA sit when placed?

A

On vocal cords, note: only offers partial (not 100%)airway protection

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23
Q

Why does air go into the lungs if you place a small amount of positive pressure onto the patient?

A

The trachea is the path of least resistance

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24
Q

An endotracheal tube has what at the end?

A

A small balloon

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25
Q

Where does an endotracheal tube sit when placed?

A

In trachea right above main bronchi

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26
Q

When passing endotracheal tubes between the vocal cords, if go to far, which lung will the tube go into and why?

A

Into right lung because it is the straighter bronchus

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27
Q

What gives the 100% seal for endotracheal tubes?

A

Inflation of the balloon end

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28
Q

Yellow indicates what gas?

A

Air

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29
Q

Green indicates what gas?

A

Oxygen

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30
Q

Blue indicates what gas?

A

Nitrous oxide

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31
Q

Is the anesthesia machine a closed or open system?

A

Closed, so it has a CO2 scavenger (Soda Lime)

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32
Q

What are 4 things that must be considered for inhalation anesthesia?

A
  1. Equilibration
  2. MAC
  3. Blood gas solubility
  4. Stages of anesthesia
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33
Q

The partial pressure of all gases will try to do what throughout the body?

A

Equilibrate (in alveoli, blood, body tissue)

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34
Q

Do all body tissues equilibrate to gases at the same rate?

A

No

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35
Q

The movement of gases in the body is determined by what?

A

Equilibration

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36
Q

Which tissues equilibrate quickly?

A

VRG (vessel rich group) = brain, heart, kidney, gut

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37
Q

What tissue is intermediate in its equilibration time?

A

VIG (vessel intermediate group) = muscle

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38
Q

What is the concentration of an anesthetic at which 50% of patients will not respond to a noxious stimulus (considered a measure of potency and is used to guide the correct dosages of agents)?

A

Minimum alveolar concentration (MAC)

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39
Q

Induction usually occurs at how many MAC?

A

2-3 MAC

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40
Q

Maintenance after induction usually takes place at how many MAC?

A

0.5-1.5 MAC

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41
Q

Are MACs independent or cumulative?

A

Cumulative, must consider other drugs used on the patient when considering MAC for a certain drug

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42
Q

When determining the stages of anesthesia, what must always be considered?

A

The drugs that mask/mimic signs, e.g. atropinecauses pupil dilation

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43
Q

Guedel’s stages of anesthesia based on what?

A

Ether

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44
Q

What are the 4 stages of anesthesia?

A
  1. Analgesia
  2. Excitement
  3. Surgical Anesthesia
  4. Apnea
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45
Q

What are the characteristics of a Stage 1 anesthesia patient?

A

They are conscious but do not feel pain

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46
Q

Stage 2 of anesthesia begins when and why?

A

Starts at loss of consciousness as patient begins to lose protective reflexes. Jerking caused by inhibition of
inhibitory CNS.

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47
Q

At what anesthesia stage is surgery performed?

A

Stage 3 surgical anesthesia

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48
Q

Do current inhalationals induce Apnea (Stage IV anesthesia)?

A

No

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49
Q

What is the coefficient that represents the ability of an agent to dissolve in blood?

A

Blood gas solubility

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50
Q

Only blood that (pick one) is or is not dissolved in blood can see the brain to produce effects?

A

Only NOT dissolved

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51
Q

What Blood Gas solubility / Blood Gas coefficient (BGC) is desired?

A

Lower the BGC, the faster the rise in arterial gas tension

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52
Q

What does a low BGC mean for both onset and recovery?

A

Both onset and recovery will be fast

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53
Q

Nitrous has a high or low BGC?

A

Low, starts within a few breaths and gone within 5 minutes on 100% oxygen

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54
Q

What are 5 minor inhalational agents?

A
  1. Ethyl chloride
  2. Chloroform
  3. Diethyl ether
  4. Methoxyflurane
  5. Nitrous oxide
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55
Q

What are 5 major inhalational agents?

A
  1. Halothane
  2. Enflurane
  3. Isoflurane
  4. Desflurane
  5. Sevoflurane
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56
Q

Of the 5 major inhalationals, which has liver toxicity and epinephrine sensitivity?

A

Halothane

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57
Q

Of the 5 major inhalationals, which can have seizure activity?

A

Enflurane

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58
Q

Of the 5 major inhalationals, which has the lowest BGC [0.42], so is very fast in/fast out, but is expensive?

A

Desflurane

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59
Q

What is the MAC of desflurane?

A

6

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60
Q

What are the cardiac actions of desflurane?

A

Tachycardia, but no change in cardiac output

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61
Q

With regards to the breathing associated with desflurane, what is increased?

A

The breathing is fast and shallow breathing

The PaCO2 increases

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62
Q

All inhalants cause some type of what?

A

Ionotropism

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63
Q

Most inhalants do what to heart stroke volume, and how does the body compensate?

A
  1. Decrease stroke volume

2. Compensate with tachycardia to maintain cardiac output

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64
Q

What is the concern with tachycardia and the heart (think when the heart gets fed)?

A

Heart gets fed during diastole. Diastole decreases in tachycardia, so heart is fed less.

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65
Q

In what patients is tachycardia a concern and why?

A

Cardiac patients and elderly. They have less cardiac reserve to compensate for less heart “feeding”during tachycardia.

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66
Q

All inhalationals do what to tidal volume: increase or decrease?

A

Increase Tidal volume

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67
Q

If all inhalationals increase tidal volume, why does the patient’s PaCO2 increase?

A

Because they cause tachypnea

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68
Q

What is the MAC of Isoflurane?

A

1.2 (potent)

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69
Q

Can induction be done with Isoflurane or Desflurane and why?

A

No, both are pungent and patient will hold breath

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70
Q

What are the cardiac effects of isoflurane?

A

Isoflurane has minimal cardiac effect, increases the HR by 10%

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71
Q

What are 2 positive characteristics of Isoflurane with respect to airway?

A
  1. Good bronchodilator

2. Good muscle relaxation

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72
Q

Isoflurane, being a good bronchodilator, would be indicated in what type of patient?

A

Asthmatic

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73
Q

What is a consideration as dentists for Isoflurane being a good muscle relaxer?

A

Makes the mouth easier to open when the patient asleep

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74
Q

What is the most common inhalational, besides N2O, used by our OMFS, with a low blood gas solubility (quick in, quick out)?

A

Sevoflurane

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75
Q

Because Sevoflurane has very little irritation, what can it be used for?

A

Used for induction (breath the patient down)

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76
Q

What is the MAC of Sevoflurane?

A

1.71

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77
Q

What are the cardiac effects of Sevoflurane?

A

Decreases both tidal volume and rate

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78
Q

Sevoflurane is a triggering agent for this which hasa high fatality that can only be diagnosed by a family history or muscle biopsy. Occurs when every muscle in body starts moving, producing CO2, and generating heat increasing the overall body temperature?

A

Malignant hyperthermia

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79
Q

High flow rate of Sevoflurane is required to prevent what?

A

Compound A toxicity (compound A is degradation product of Sevo, shown to cause renal necrosis in rats

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80
Q

What is the disdavantage of oral medication dosing?

A

It is upredictable

81
Q

Giving a drug via the floor of the mouth is equivalent to giving it through what other method?

82
Q

What is the disadvantage of subcutaneous dosing?

A

slow absorption

83
Q

Intrathecal is dosing where?

A

Into dural spaces

84
Q

What is the disadvantage of intramuscular dosing?

A
  1. Predictable
  2. Titratable (small doses to patient until the patient is at the sedation level you desire)
  3. IV allows possibility of quick dosing of reversal agents
85
Q

What are 8 general IV agents?

A
  1. Narcotics
  2. Benzodiazepines
  3. Barbiturates
  4. Non-barbiturates Induction Agents
  5. Ketamine
  6. Anticholinergics
  7. Reversal agents
  8. Muscle relaxants
86
Q

What stage do you want patients in for general anesthesia?

87
Q

What stage do you NOT want patients in for general anesthesia?

88
Q

What stage do you want to be in if you are on NO2?

89
Q

What are two reasons to give narcotics?

A
  1. Sedation

2. Analgesia

90
Q

All narcotics are in what category of drugs?

A

Analgesics

91
Q

Narcotics acting on Mu receptors cause what?

92
Q

Narcotics acting on Kappa receptors cause what?

A
  1. Analgesia
  2. Nausea and vomiting
  3. Dysphoria
  4. Decreased motility (autonomic)
93
Q

Narcotics acting on sigma receptors can cause what?

94
Q

All narcotics are___ and induce ____?

A

All narcotics are ADDICTING and induce TOLERANCE

95
Q

Is the major effect of narcotics on the reaction to pain or perception of pain?

A

The reaction to pain

96
Q

What are 3 things all narcotics cause?

A
  1. Respiratory distress
  2. Nausea
  3. Constipation
97
Q

Narcotics are indicated for treatment of what pain type: severe, sharp or constant dull?

A

Severe, sharp (e.g. not indicated for TMD patient)

98
Q

What is the term for the need for increasing doses to get same effect of a narcotic?

99
Q

What is the term for the onset of physiological symptoms following the removal or lack of a narcotic?

A

Withdrawal

100
Q

What is the term for the physical need for repeated doses of narcotic to prevent withdrawal?

A

Dependence

101
Q

What are the 3 divisions of narcotics?

A
  1. Opiates
  2. Synthetic opiates
  3. Opiodes (synthetic compounds)
102
Q

Morphine and codeine are what type of narcotics?

103
Q

Diluadid and Heroine are what type of narcotics?

A

Synthetic opiates

104
Q

Fentanyl, Demerol, Alphaprodine are what type of narcotics?

105
Q

What is THE prototypical narcotic?

A

Morphine (opiate)

106
Q

What is 1 symptom of narcotic use that does not have tolerance?

A

Meiosis (pupil constriction/pinpoint pupils)

107
Q

What is a single dose of morphine?

A

2-13 mg, IV is shorter lasting (1-2 hrs) than IM (8 hrs)

108
Q

Morphine is indicated in what patient?

A

Myocardial infarction patient due to minimal CVS effects when supine

109
Q

Demerol (synthetic opiod) has an anticholinergic effect which means it will sedate WHICH autonomic system more: parasympathetic or sympathetic?

A

Parasympathetic because acetylcholine is the final transmitter in PNS, sympathetic takes over

110
Q

What is the dosing of demerol?

A

50-100 mg IM

25-50 mg IV slowly

111
Q

Demerol indicated when in surgery?

A

Postop analgesia

112
Q

Which narcotic is 1000X stronger than morphine with a fast onset (3 min) and short duration (15-30 min IV)?

113
Q

What is the dosage of fentanyl?

A

1 microgram/kg or

50-100 mc (.05 mg-.1mg) not to exceed 100 mcg

114
Q

What syndrome is associated with fentanyl dose exceeding 100 mcg, which makes them unable to ventilate?

A

Stiff chest syndrome

115
Q

What class of drugs that are sedative hypnotics are used for relaxation and reduction of anxiety?

A

Benzodiazepines

116
Q

What 2 systems to benzodiazepines act on?

A
  1. Limbic system

2. Reticular activating system

117
Q

Benzodiazepines increase what neurotransmitter in the limbic and reticular activating system?

A

GABA (inhibitory neurotransmitter)

118
Q

What are 2 short-acting (2-5 hrs) benzodiazepines?

A
  1. Midazolam (Versed)

2. Triazolam (Halcion)

119
Q

What is 1 medium-acting (10-20 hrs) benzodiazepine?

120
Q

What is 1 long-acting benzodiazepine?

A

Diazepam (Valium)

121
Q

What is a benzodiazepine used for oral sedation?

A

Triazolam (Halcion) (short-acting 2-5 hrs)

122
Q

What benzodiazepine is used for IV sedation?

A

Midazolam (Versed) (short-acting 2-5 hrs)

123
Q

What is the “gold-standard” benzodiazepine?

A

Diazepam (Valium) (long-acting 20-80 hrs)

124
Q

Benzodiazepines are good for what beyond sedation and anxiolysis?

A
  1. Anticonvulsant

2. Muscle relaxant

125
Q

Which is more potent: versed or valium?

126
Q

Which has more pain on injection: versed or valium?

A

Valium because it is oil-soluble and therefore is mixed with propylene glycol which also risks thrombophlibitis

127
Q

Which produces more anterograde amnesia: valium or versed?

128
Q

Which produces more respiratory depression: valium or versed?

129
Q

What are the only characteristics in which Valium exceeds Versed?

A
  1. Risk of thrombophlibitis

2. Duration (Valium 8-24 hrs)

130
Q

Valium and Versed are both metabolized into what?

A

An active metabolite

131
Q

What is the active metabolite of benzodiazepam that can be given to liver patients to sedate them so as to not work the liver?

A

Oxazepam (Serax)

132
Q

Barbiturates can be used as what type of agents?

A
  1. Induction

2. Sedation

133
Q

What is the principle method of action of barbiturates?

A

Redistributeion: goes to brain, puts to sleep, then goes to rest of body from the brain

134
Q

What is the principle area of metabolism for barbiturates?

A

Liver at 20%/hr

135
Q

What are 3 categories of barbiturates?

A
  1. Ultra-short acting
  2. Short acting
  3. Long-acting
136
Q

What is the site of action for barbiturates?

A

Reticular activating system

137
Q

If you give a barbiturate, will the patient feel pain?

138
Q

At low doses, barbiturates will cause the patient to do what?

A

Release inhibitions

139
Q

What is the character of the solution of barbiturates?

A

High pH = caustic

140
Q

What is acute intermittant porphyria, a contraindication for giving a barbiturate?

A

Can’t break down the hemoglobin ring, causing CNS problems

141
Q

What barbiturate used for induction in a GA case?

A

Thiopentol (Pentothal)

142
Q

The barbiturate thiopental/pentothol can cause what?

A

Severe histamine release

143
Q

What is the induction dose for barbiturate pentothol?

144
Q

What is the standard solution for barbiturate methohexital (brevital)?

A

1% solution

145
Q

What are the cardiac effects of the barbiturate methohexital?

A
  1. Increased HR
  2. Decreased total peripheral resistanct
  3. Decreased BP
  4. Level cardiac output due to the compensatory tachycardia
146
Q

What is common with barbiturate methohexital (brevital)?

147
Q

Can barbiturate methohexital (Brevital) affect laryngeal/pharyngeal reflexes?

148
Q

Will barbiturate methohexital (Brevital) depress respiration?

A

Yes it is dose dependent

149
Q

What non-barbiturate induction agent is short-acting (and was involved in Michael Jackson’s death)?

150
Q

What is a consideration for propofol injection?

A

It burns (suspended in soybean fat). Consider giving lidocaine.

151
Q

What depresses with non-barbiturate induction agent propofol?

A
  1. Tidal volume decreases for 4 minutes
  2. BP decreases 25%
  3. Cardiac output decreases
152
Q

What is a non-narcotic, non-barbiturate, rapid-acting induction or sedative agent that gives profound analgesia (and the patient does not appear asleep)?

153
Q

Ketamine does what to CVS and CNS?

A
  1. Stimulates CVS increasing HR and BP

2. Stimulates CNS

154
Q

Why does a patient on ketamine patient appear to be awake?

A

It is a dissociative anesthetic

155
Q

Why is the fact that ketamine is a cardiac stimulant a consideration?

A

Consider for trauma with high blood loss: do not want to desate with barbiturate as those will decrease BP

156
Q

What are 2 patients that ketamine is contraindicated in?

A
  1. Epileptic

2. High blood pressure

157
Q

Why is ketamine better for children and not adults?

A

Adults can have hallucinations

158
Q

Anticholinergics can be used as what agents?

A
  1. Antisialologue

2. Positive chronotrope (increased HR)

159
Q

Anticholinergices inhibit what system and why?

A

Parasympathetic because the postganglionic transmitter is acetylcholine

160
Q

Anticholinergics allow which system to take over and exert its effects?

A

Sympathetic

161
Q

What are 2 anticholinergics (things that will increase the sympathetic nervous system by inhibiting the parasympathetic nervous system)?

A
  1. Atropine

2. Robinol (glycopyrrolate)

162
Q

Atropine, an anticholinergive, is given to adults for what reason?

A

Antisialolgue

163
Q

Atropine, an anticholinergic, given to children for what reason?

A

Increased HR

164
Q

What is the dosage of atropine (anticholinergic)?

165
Q

Robinul (glycopyrrolate) (anticholinergic) is stronger/weaker than atropine and what is the dose?

A
  1. Stronger (increased drying and HR)

2. Does is 1/2 atropine (i.e. 0.2-0.5 mg)

166
Q

Drugs that reverse the effects of other drugs and are used in emergencies or for emergence (from sedation)?

A

Antagonists

167
Q

What narcotic is a pure antagonist (the only pure antagonist in clinical use)?

A

Narcan/Naloxone

168
Q

If you give a narcotic antagonist (Narcan/naloxone) to a patient with no narcotic on board, will there be an effect?

169
Q

What is the dosage of narcan/naloxone?

170
Q

What is a narcotic antagonist that is a mixed agnoist-antagonist?

A

Pentazocine (Talwin)

171
Q

What are the primary bad effects of narcotics?

A

Respiratory depression

172
Q

What is an ER patient given who is unconscious for an unknown reason?

A

Naloxone (Narcotic reversal agent)

173
Q

What is a reversal agent for most benzodiazepines?

A

Flumazenil (Romazicon)

174
Q

Will Flumazenil (benzodiazepine reversal agent) work on narcotics, barbiturates, or ethanol?

175
Q

If a patient is addicted to benzodiazepines (valium, versed), what will flumazenil dose trigger?

A

Withdrawal symptoms and seizures

176
Q

Will flumazenil reverse both the sedative and respiratory depression of benzodiazepines or just one of these?

A

Just sedation, will not reverse respiratory depression

177
Q

Muscle relaxants paralyze what muscles?

178
Q

Depolarizing muscle relaxant acts how?

A

Acetylcholine analogue attaches to skeletal motor end plate, causing it to depolarize

179
Q

How will a patient act when given a depolarizing muscle relaxant?

A

Twitch (depolarization) then go flaccid

180
Q

What is an example of a depolarizing agent?

A

Succinylcholine

181
Q

What is the duration and the reason for use of a depolarizing muscle relaxant succinylcholine?

A

5 minute duration

Paralyze vocal cords to put in endotracheal tube

182
Q

Repeated doses of the depolarizing muscle relaxant succinylcholine will cause what?

A

Bradycardia

183
Q

How do non-depolarizing muscle relaxants work?

A

Block the motor end plate so no acetylcholine can activate them

184
Q

List the non-depolarizing muscle relaxants from shortest to longest-acting.

A

Mivacurium < Atracurium < Rocuronium < Vecuronium < Pancuronium

185
Q

Non-depolarizing muscle relaxants can be reversed with what?

A

Neostigmine (acetylcholinesterase inhibitor)

186
Q

What was the first muscle relaxant (derived from poison dart frogs)?

A

Curare (note that all the non-depolarizers have tha in the middle of their name)

187
Q

What are the advantages and disadvantages of using the antecubital fossa for IV?

A

A large vein better for caustic drug admin (e.g. barbiturates) Disadv for long term IV

188
Q

What are some vital sign monitors for sedation/GA?

A 
BP
O2 saturation 
CO2
ECG
Temperature
189
Q

Is there a certain amount of a drug that always corresponds to every level of sedation every time?

190
Q

When doing sedation, what should you always plan for?

A

To get deeper than expected (patient unable to breathe for themselves)

191
Q

What is the level of sedation where the patient is awake and responsive?

A

Conscious sedation/light-moderate IV sedation

192
Q

What is the cocktail normally used for conscious sedation?

A

Benzodiazepine +/- narcotic

193
Q

Why would fentanyl be preferred as the narcotic in conscious sedation over demerol?

A

Because Demerol has anticholinergic effects, raising the HR and lasting longer

194
Q

What type of sedation may result in the patient not being able to respond to commands but they should be able to maintain their own airway?

A

Deep IV sedation

195
Q

What is the cocktail for deep IV sedation?

A
  1. Heavy dose benzodiazepine
  2. Heavier dose of narcotic
  3. Small dose barbiturate or propofol
196
Q

Why is the barbiturate or propyphol given for a deep IV sedation?

A

To get the patient to sleep

197
Q

What type of sedation results in the patient being unresponsive and unable to maintain his or her own airway and a loss of protective reflexes?

A

General anesthesia

198
Q

What is the cocktail for GA?

A

5mg Midozalam (Benzodiazepine)
100 mcg Fentanyl (Narcotic)
30 mg propofol or Brevital (barbiturate) to induce, then give bolus of propofol every 5 min

199
Q

When planning Laryngeal Mask Airway (LMA) anesthesia, what can be inhaled to aide while placing the LMA?

A

Sevoflurane 3-4 MAC, then maintain with 1-1.5 MAC

200
Q

Is airway security absolute with LMA even if you can ventilate?

xD3 Pharm Exam 1 (4 decks)

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