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UPR-RCM SRNA PHARM I > APEX: Inhaled Anesthetics QUIZ > Flashcards

APEX: Inhaled Anesthetics QUIZ Flashcards

1
Q

Which anesthetic is shown in the image below?

A

Sevoflurane

Easy way to remember is to count the Flouride atoms. Sevo has 7

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2
Q

Anesthetics are categorized into three groups:

A
  1. Ethers
  2. Alkenes
  3. Gases
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3
Q

What gases are considered Ethers?

Think: DIS

A
  1. Desflurane
  2. Isoflurane
  3. Sevoflurane
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4
Q

What are some gases that exist in gaseous form?

A
  1. Nitrous oxide
  2. Xenon
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5
Q

How many fluorine atoms are in the following halogenated gases:

  1. Halothane
  2. Isoflurane
  3. Sevoflurane
  4. Desflurane
A
  1. Halothane = 3
  2. Isoflurane = 5
  3. Desflurane = 6
  4. Sevoflurane = 7
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6
Q

Does the chlorine atom in Isoflurane increase or decrease potency?

A

Increases potency

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7
Q

What is the difference between Desflurane and Isoflurane’s chemical structure?

A
  • The substitution of the fluorine atom in desflurane for the chlorine atom in isoflurane
  • Leads to significant differences in their pharmacokinetic properties
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8
Q

What is the potency of Sevoflurane compared to Desflurane?

A

Sevoflurane is ~ 3 times as potent as Desflurane.

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9
Q

What is Vapor Pressure

A
  • Is the pressure exerted by a vapor in equilibrium with its liquid or solid phase inside of a closed container
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10
Q

What is boiling point?

A
  • Is the temperature where matter transitions from a liquid state to a gas state.
  • Open container
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11
Q

When does boiling occur?

A
  • When vapor pressure is equal to atmospheric pressure
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12
Q

What does Dalton’s law of partial pressure says?

A
  • The total gas pressure in a container is equal to the sum of the partial pressures exerted by each gas.
  • P total = P1 + P2 + P3…
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13
Q

Vapor pressure is less than?

A

Atmospheric pressure

In relation to Evaporation

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14
Q

Boiling requires an open or closed container?

A

Open container

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15
Q

↑ atmospheric pressure → ?

A

↑ boiling point

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16
Q

↓ atmospheric pressure → ?

A

↓ Boiling point

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17
Q

What is Partial Pressure?

A
  • The pressure exerted by a vapor in equilibrium with its liquid or solid phase inside of a closed container
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18
Q

What does Dalton’s law of Partial Pressures say?

A
  • The total gas pressure in a container is equal to the sum of the partial pressure exerted by each gas.
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19
Q

How is the depth of Anesthesia determined?

A
  • By the partial pressure of an anesthetic gas agent in the brain.
  • NOT the volume percent.
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20
Q

Is Sevoflurane stable or unstable in hydrated soda lime?

A

Unstable

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21
Q

Desflurane and Isoflurane can become unstable in desiccated soda lime and produce:

A
  • Carbon monoxide
  • Des > Iso
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22
Q

What’s Sevo Vapor pressure?

A

157 mm Hg

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23
Q

What’s Des vapor pressure?

A

669 mm Hg

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24
Q

What’s Iso vapor pressure?

A

238 mmHg

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25
Q

What’s Nitrous oxide vapor pressure?

A

38, 770 mmHg

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26
Q

What is the Boiling point (degrees C) of the following gases?

  1. Des
  2. Iso
  3. Sevo
  4. N2O

Think: D-I-S order lowest to highest + N2O

A
  1. Des= 22 celcius
  2. Iso = 49 celcius
  3. Sevo = 59 celcius
  4. N2O = -88 celcius
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27
Q

What is the Molecular weight (g) of Sevoflurane?

A

200 g

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28
Q

What is the Molecular weight (g) of Desflurane?

A

168 g

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29
Q

What is the Molecular weight (g) of Isoflurane?

A

184 g

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30
Q

What is the Molecular weight (g) of Nitrous oxide?

A

44 g

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31
Q

Do the following inhaled anesthetic gases require a Preservative?

  1. Sevo
  2. Des
  3. Iso
  4. N2O
A

No

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32
Q

Which inhaled anesthetic gases are the only ones stable in hydrated CO2 absorber?

Think: D-I-N

A
  1. Des
  2. Iso
  3. N2O
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33
Q

Which inhaled anesthetic gases are stables on Dehydrated Co2 absorber?

A
  • Nitrous Oxide only!
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34
Q

What is the toxic By-product of Sevoflurane?

A

Compound A

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35
Q

What is the toxic By-product of Desflurane and Isoflurane?

A
  • Carbon monoxide
  • Des > Iso
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36
Q

In what kind of solvent Will a Polar solute will be more soluble?

A
  • In a Hydrophilic solvent
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37
Q

In what kind of solvent Will a Non-Polar solute will be more soluble?

A
  • In a Lipophilic solvent
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38
Q

What is gas solubility?

A
  • The ability of the anesthetic agent to dissolve into the blood and tissues
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39
Q

How is solubility measure?

A
  • The partition coefficient
  • Describes the relative solubility of a solute in two different solvents
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40
Q

What are the Partition Coefficients of Sevo?

A
  • Blood:gas = 0.65
  • Brain:blood = 1.7
  • Muscle:blood = 3.1
  • Fat:blood = 47.5
  • Oil:gas = 47
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41
Q

What are the Partition Coefficients of Desflurane?

A
  • Blood:gas = 0.42
  • Brain:blood = 1.3
  • Muscle:blood = 2.0
  • Fat:blood = 27.2
  • Oil:gas = 19
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42
Q

What are the Partition Coefficients of Isoflurane?

A
  • Blood:gas = 1.46
  • Brain:blood = 1.6
  • Muscle:blood = 2.9
  • Fat:blood = 44.9
  • Oil:gas = 91
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43
Q

What are the Partition Coefficients of Nitrous Oxide?

A
  • Blood:gas = 0.46
  • Brain:blood = 1.1
  • Muscle:blood = 1.2
  • Fat:blood = 2.3
  • Oil:gas = 1.4
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44
Q

What does FA stand for?

A
  • Alveolar Gas Concentration
  • The partial pressure of the anesthetic inside the alveoli
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45
Q

What does FI stands for?

A
  • Inspired Gas Concentration
  • The concentration of the anesthetic exiting the vaporizer
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46
Q

The FA/FI Curve of inhalation agents- Recognize it!

A
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47
Q

Factors that influence the rate of anesthetic delivery to the alveoli:

A
  • Setting the vaporizer
  • Fresh gas flow
  • Time constant of the delivery system
  • Anatomic dead space
  • Alveolar ventilation
  • Functional residual capacity (FRC)
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48
Q

Factors that influence the removal of anesthetic from the Alveoli:

A
  • Blood:gas solubility
  • Partial pressure difference between the alveoli and the blood
  • Cardiac output
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49
Q

What are the Determinants of Tissue uptake(absorption)?

A
  • Tissue:blood solubility
  • Tissue blood flow
  • Partial pressure difference between arterial blood and tissue
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50
Q

What are the factors that ↑ Wash in?

A
  • ↑ FGF
  • ↑ Alveolar ventilation
  • ↓ FRC
  • ↓ Time constant
  • ↓ anatomic dead space

Increased FA/FI = Faster onset curve push-up

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51
Q

What are the factors that ↓ Uptake?

A
  • ↓ solubility
  • ↓ Cardiac output
  • ↓ Pa-Pv difference

Increased FA/FI = Faster onset curve Pushed up

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52
Q

What factors lead to ↓ Wash in?

A
  • ↓ FGF
  • ↓ Alveolar filtration
  • ↑ FRC
  • ↑ Time constant
  • ↑ Anatomic dead space

Decreased FA/FI = Slower Onset Curve Pushed Down

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53
Q

What factors lead to ↑ Uptake?

A
  • ↑ Solubility
  • ↑ Cardiac output
  • ↑ Pa-Pv difference

Decreased FA/FI = Slower Onset Curve Pushed Down

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54
Q

What percentage of body weight is accounted for by the vessel-rich group?

A

10%

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55
Q

Tissue uptake depends on:

A
  • Tissue blood flow
  • Solubility of the anesthetic in the tissue
  • Arterial blood:tissue partial pressure gradient
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56
Q

Which organs are included in the Vessel-Rich Group?

A
  • Heart
  • Brain
  • Kidneys
  • Liver
  • Endocrine glands
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57
Q

What percentage of cardiac output does VRG receive?

A

75%

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58
Q

What is the percentage of body mass of the muscle/skin group?

A

50%

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59
Q

What percentage of cardiac output does the muscle/skin group receives?

A

20%

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60
Q

What is the percentage of Body Mass of the Vessel-Poor group?

A

20%

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61
Q

What is the percentage of cardiac output receive by the Vessel-Poor Group?

A

< 1%

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62
Q

What is the percentage of cardiac output receive by the Fat group?

63
Q

What is the percentage of Body Mass of the Fat group?

64
Q

Which organs are included in the Vessel-Poor Group?

A
  • Bone
  • Tendon
  • Cartilage
65
Q

Which organs are included in the Muscle group?

A
  • Skeletal muscle
  • Skin
66
Q

Which body group receives most of the anesthetic agent during induction and are the first to equilibrate with FA?

A

Vessel-Rich Group

67
Q

What is the order of body group from first to last of anesthetic agent uptake?

A
  1. Vassel-Rich Group
  2. Muscle Group
  3. Fat Group
  4. Vessel-Poor Group
68
Q

Biotransformation THINK: DISH-N

69
Q

Inhaled anesthetics are eliminated from the body in three ways:

A
  1. Elimination from the alveoli (primary mechanism)
  2. Hepatic biotransformation (secondary mechanism)
  3. Percutaneous loss ( minimal and not clinical significant)
70
Q

By which system do Halogenated anesthetics undergo Hepatic Biotransformation?

A
  • P450 system
71
Q

What are the metabolites produced by Desflurane and Isoflurane?

A

Trifluoroacetic Acid

Small risk of immune-mediated hepatic dysfunction

72
Q

What metabolites are produces by Sevoflurane?

A

Free Fluoride Ions

Theoritical risk of high output kidney failure

73
Q

When expose to Soda Lime, Sevoflurane generates:

A

Compound A

Desiccated soda lime accelerates Compound A production.

74
Q

When exposed to Desiccated Soda Lime, Desflurane and Isoflurane generates:

A

Carbon monoxide

75
Q
A

You should remember “The rule of 2’s” → (0.02, 0.2, 2, and 20) Additionally, you should notice that halogenated agents spell DISH

76
Q
A

Halothane only produces Trioflouroacetic Acid

77
Q

What percentage of Halothane goes under hepatic biotransformation?

78
Q

What is the metabolic by-product of Halothane metabolism?

A
  • Trifluoroacetic acid (TFA)
79
Q

High concentration of Trifluoroacetic acid (TFA) in the liver leads to:

A

Halothane Hepatitis

Liver is the primary mechanism for immune-mediated hepatic dysfunction (Halothane hepatitis)

80
Q

Desflurane and Isoflurane are metabolized to:

A
  • Inorganic fluoride ions
  • Trifluoroacetic acid (TFA)
81
Q

Sevoflurane is NOT metabolized to TFA, but its biotransformation does result in the liberation of:

A

Inorganic Fluoride Ions

83
Q

Renal failure produced by Sevoflurane is characteristically unresponsive to:

A

Vasopressin

84
Q

Signs of high output Renal failure include:

A
  • Polyuria
  • Hypernatremia
  • Hyperosmalarity
  • ↑ Plasma Creatine
  • Inability to concentrate urine
85
Q

Nitrous oxide is not metabolized by the ______

86
Q

What are the FDA’s recomendations to prevent Compound A buildup?

A
  • FGF of 1 L/min for up to 2 MAC-hr
  • FGF of 2 L/min after 2 MAC-hr
  • FGF rates < 1 L/min are not recommended
87
Q

What is MAC-hr?

A
  • Is Minimun alveolar concentration
  • Prevents movement in response to a noxious stimulus 50% of subjects (MAC) after 1 hour.
88
Q

Which P450 enzyme is chiefly responsible for halogenated anesthetic metabolism in the liver?

89
Q

What by-product of halothane metabolism has been implicated in causing halothane hepatitis?

A

Trifluoroacetic acid (TFA)

90
Q

Which concept BEST explain why the rate of rise of FA/FI is faster for Nitrous Oxide than Desflurane?

A

Concentration effect

91
Q

What factors alter the speed of anesthetic induction and emergence?

A
  • Concentration effect
  • Ventilation effect
92
Q

What are the two components of Concentration effect?

A
  1. Concentrating effect
  2. Augmented Gas Inflow effect
93
Q

How many more times is Nitrous Oxide more soluble in the blood than Nitrogen?

A

~ 34 times

94
Q

The concentration effect only applies to which anesthesia phase?

95
Q

The greater the alveolar ventilation, the ___________ the rate of rise of FA/FI

A
  • the GREATER the rate of rise of FA/FI
96
Q

How does the concentration effect affect the rate of rise on the FA/FI curve?

A
  • The higher the concentration of inhalation anesthetic delivered to the alveolus the faster its onset of action
97
Q

What is the ventilation effect?

A
  • Changes in alveolar ventilation affect the rate of rise of FA/FI
98
Q

What is the definition of Second Gas Effect?

A
  • Describes the consequences of the concentration effect when a second gas is co-administered
  • Administering one gas during anesthetic induction (N2O) will hasten the onset of a second gas (volatile agent)

Hasten: Makes the process quicker

99
Q

What the definition of Diffusion Hypoxia?

A
  • Movement of N2O from the tissue back into alveoli during emergence
100
Q

Identify on the graph below which line of Iso is with and without Nitrous oxide.

101
Q

What is the ranking of higher blood:gas solubility of inhaled anesthetics?

A

Iso > Sevo > Des

102
Q

How many litters of Nitrous oxide can the body gas-containing areas absorb within the first two hours of administration?

A

Up to 30 L

103
Q

Does the second gas effect have a more meaningful impact on Iso or Sevo? Why?

A
  • It produces a more meaningful benefit with agents of higher blood:gas solubility
  • Iso > Sevo > Des
104
Q

What is the best way to mitigate diffusion hypoxia after nitrous oxide is discontinue?

A
  • ↑ FiO2 for 3-5 min after d/c N2O
  • It does not have to be 100% though
105
Q

Which volatile agent is affected the MOST by a Right-to-Left cardiac shunt?

A

Desflurane (blood:gas 0.42)

A right-to-left cardiac shunt slows the speed of induction with a volatile agent. It takes longer for FA to equilibrate with FI.
Agents with slow solubility (Desflurane) are affected the most
Agents with high solubility (Isoflurane) are affected the least

106
Q

How does Right-to-left shunt affects the onset of volatile and intravenous anesthetics?

A
  • Slower induction with volatile agents
  • Faster induction with an IV agent
107
Q

How does Left-to-Right shunt affects the onset of volatile and intravenous anesthetics?

A
  • No miningful impact on induction with volatile agents
  • Slower induction with IV agents
108
Q

What are some examples of Right-to-Left shunts?

A
  • Tetralogy of Fallot
  • Foramen ovale
  • Eisenmenger’s syndrome
  • Tricuspid atresia
  • Ebstein’s anomaly
109
Q

Which volatile agent is affected the LEAST by a Right-to-Left cardiac shunt?

A

Isoflurane (blood:gas 1.46)

110
Q

Which anesthetic agent has a blood:gas solubility coefficient of 0.46?

A

Nitrous oxide

111
Q
A

Fluoromethyl 2,2,2-trifluoro-1-(trifluoromethyl) ethyl ether (Sevoflurane)

112
Q

Full fluorination of an anesthetic agent will MOST likely reduce:

A
  • ↓ Potency
  • ↓ Metabolism
113
Q

Which anesthetic agents bear the closest chemical resemblance?

A
  • Desflurane
  • Isoflurane
114
Q

The FA/FI curve of which anesthetic agent is MOST significantly impacted by the concentration effect?

A

Nitrous oxide

Higher the concentration of inhalation anesthetic delivered to the alveolus (FA), the faster its onset of action (this is also called over pressuring).

115
Q

Which anesthetic agent undergoes the GREATEST degree of elimination from the lungs?

A

Desflurane

116
Q

Which physiochemical reaction occurs when a liquid’s vapor pressure equals atmospheric pressure?

117
Q

In which cells would the concentration of Sevoflurane be expected to rise the FASTEST during anesthetic induction?

A

Hepatocytes

118
Q

Which factors have the MOST significant impact on anesthetic uptake into the blood?

A
  1. Blood:gas solubility
  2. Cardiac output
  3. Partial pressure difference between the alveolar gas and mixed venous gas
119
Q

The blood:gas partition coefficient MOST closely correlates with:

A

Speed of emergence

120
Q

What is determined by the Partial Pressure (PP)?

A

Depth of Anesthesia

121
Q

Which anesthetic gases are not affected by elevation?

A
  • Sevoflurane
  • Isoflurane

This is because the conventional variable bypass vaporizer automatically compensates for the elevation change.

122
Q

Which Anesthetic gas uses the Tec 6 Vaporizer?

A

Desflurane

123
Q

The Fa/FI curve allow us to predict :

A

The speed of induction

124
Q

Low solubility =

A

Faster Onset

125
Q

High solubility =

A

Slower Onset

126
Q

What conditions increase FA/FI?

A

For FA/FI to increase, there must be:
* ↑ Wash in
* ↓ Uptake

127
Q

What conditions decrease FA/FI?

A

For FA/FI to decrease, there must be a reduced Wash in and/or increase uptake

128
Q

What is the ranking of potency for inhaled anesthetics from most to least (oil:gas)?

A

Iso > Sevo > Des

129
Q

How does the addition of Chlorine atom affect Isoflurane’s PK/PD profile

A
  • ↑ Potency
  • ↑ Blood:gas solubility
130
Q

Carbon dioxide absorbent, as well as the liver, can transform volatile anesthetic into:

A

Toxic compounds

131
Q

What is Gas Stability?

A
  • Ability to resist to breakdown or metabolism
132
Q

What are the four key physiochemical concepts of inhaled anesthetics?

A
  1. Vapor pressure
  2. Boiling point
  3. Partial Pressure
  4. Stability
133
Q

What is Evaporation?

A
  • Compound transition from its liquid state to a gaseous state.
  • Below its boiling point.

Vapor pressure is < atmospheric pressure

134
Q

An Anesthetic gas with LOW blood:gas solubility is less or more likely to be taken up into the blood?

A

Is LESS likely to be taken up into the blood.

135
Q

An Anesthetic gas with HIGH blood:gas solubility is less or more likely to be taken up into the blood?

A

Is MORE likely to be taken up into the blood

136
Q
A

Nitrous Oxide

137
Q

The amount of anesthetic inside the Alveoli (FA) is a balance between:

A

Input and uptake into the blood

Input: the setting in the vaporizer

138
Q

When administering a volatile anesthetic, we produce a state of anesthesia by:

A
  • Building up partial pressure of anesthetic agent inside the patient’s brain and spinal cord .
139
Q

What is the surrogate to measure an anesthetic in the brain?

A

Alveolar Partial Pressure (FA)

Alveolar partial pressure ~ Blood partial pressure ~ Brain partial pressure

140
Q

This term, creates a concentration gradient that pushes the anesthetic agent from the vaporizer towards the alveoli:

A

FI (Inspired Gas Concentration)

141
Q

This term describes the anesthetic washes into the alveoli and establishes a partial pressure:

A

FA ( Alveolar Gas concentration)

142
Q

This term describes the build up of anesthetic partial pressure inside the alveoli is being opposed by continues uptake of the agent into the blood:

143
Q

Nitrous oxide quickly diffuses to gas containing areas in the body, such as:

A
  • GI tract
  • Middle ear
144
Q

What’s the potency of Isoflurane compared to Sevoflurane?

A
  • Isoflurane is twice as potent as Sevoflurane.

Isoflurane is 5 times as potent as Desflurane

145
Q

How does Cardiac output influence the removal of inhaled anesthetic from the alveoli?

A
  • ↑ CO → ↑ Uptake → ↓ FA (slower induction)
  • ↓ CO → ↓ Uptake → ↑ FA (faster induction)
146
Q

How does Cardiac Output affect the rate of induction of the IV agent?

A
  • ↑ CO → Faster delivery to the brain (faster induction)
  • ↓ CO → Slower delivery to the brain ( slower induction)
147
Q

How does increased cardiac output affect the speed of an inhalation induction?

A

Induction is prolonged

148
Q

Which electrolyte disorders affect MAC?

A
  • MAC increase: ↑ Na+
  • MAC decrease: ↓ Na+, ↑ Li+
  • MAC is Unchanged by K+
149
Q

During which procedures is SF6 (Sulfur Hexafluoride) placed over the retina?

A
  • Retinal reattachment
  • Vitrectomy
  • Macular hole repair
150
Q

How long is N2O avoided if the SF6(sulfur hexafluoride) bubble is placed?

A
  • Avoid N2O 15 min before SF6 is placed
  • Avoid N2O 7-10 days after SF6 is placed

N2O can expand SF6 bubble compromise retinal perfusion and cause permanent blindness.

151
Q

How long is N20 avoided if a Pefluoropropane (CF38) bubble is placed?

A
  • Avoid N2O 30 days if Perfluoropropane (CF38) after the bubble is placed.
152
Q

Which anesthetic is Methyl isopropyl ether?

A

Sevoflurane

153
Q

Which anesthetic is Methyl ethyl ether?

A
  • Desflurane
  • Isoflurane
154
Q

How does endobronchial intubation affect the speed of an inhalation induction?

A

Induction is prolonged

UPR-RCM SRNA PHARM I (7 decks)

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