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Emergency Airway Management > Ch. 21 Sedative Induction Agents > Flashcards

Ch. 21 Sedative Induction Agents Flashcards

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1
Q

What side effect is important to remember for all sedative/induction agents?

A

All cause some degree of myocardial depression and can lead to decreased BP

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2
Q

In hemodynamically unstable patients, how should analgesia be managed?

A

Remember that complete pain control may decrease catecholamine surge and lead to decreased BP and decreased organ perfusion

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3
Q

What are the preferred sedative/induction agents in order?

A

Etomidate
Ketamine
Propofol
Midazolam (very distant last resort option)

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4
Q

How does morbid obesity complicate dosing for sedative/induction agents and what should be done?

A

Increased fat => increased volume of distribution => increased dose required to work
However, sudden push of a large dose will have a larger myocardial depression effect leading to decreased BP

Use lean body weight for obesity
LBW=IBW + 0.3(TBW–IBW)
Except for propofol where IBW is better

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5
Q

Why is dosing different for elderly and what dosing should be used?

A

Elderly have decreased body water and increased fat as well as increased sensitivity to hemodynamic changes

Should use 1/2 or 2/3 of usual dose

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6
Q

What is the first choice of sedative/induction agent?

A

Etomidate

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7
Q

What is the dosing, onset, and duration for etomidate?

A

0.3mg/kg
Onset ~30sec
Lasts 5–10 minutes

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8
Q

What effects/properties does etomidate have? (sedation, analgesia, amnesia, etc.)

A

Primarily just hypnotic

No analgesia

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9
Q

What effects does etomidate have on hemodynamics?

A

Relatively none

Very stable hemodynamically

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10
Q

How does etomidate affect ICP and CPP?

A

Lowers ICP by decreased cerebral blood flow and is neuroprotective through decreased cerebral metabolic rate
Etomidate is an excellent choice for ICP patients
Maintains CPP through stable hemodynamics

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11
Q

Can etomidate be used for reactive airway patients?

A

Yes, as it doesn’t release histamine, but ketamine or propofol may be better as they have direct bronchodilatory properties

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12
Q

Can etomidate be used in pregnancy or with kids?

A

Pregnancy category C

Not FDA approved in kids, but may be ok

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13
Q

What is a side effect of etomidate that is not significant?

A

Myoclonic movements can occur and are common, but are taken care of with NMBA

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14
Q

What is the big side effect of etomidate to always remember?

A

Adrenal suppression
Lasts up to 72 hours
Decreases cortisol and aldosterone
May be significant particularly in sepsis

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15
Q

When should dose adjustments be made for etomidate?

A

Decrease dose to 0.2mg.kg in hemodynamically unstable patients
Use LBW in obese pts

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16
Q

What is the usual dose for ketamine for induction?
Onset time?
Duration?

A

1.5mg/kg
Onset 45–60 seconds (less than a minute)
Lasts 10–20 minutes

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17
Q

What effects/properties does ketamine have?

A

Analgesia, amnesia, anesthesia

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18
Q

What is a benefit to ketamine in terms of respiratory effects?

A

Preserves respiratory drive

Has bronchodilatory effects

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19
Q

How does ketamine affect hemodynamics?

A

Leads to catecholamine release => increased HR and BP as well as bronchodilation

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20
Q

What is the agent of choice for induction in asthma?

A

Ketamine

21
Q

What conditions are good to use ketamine for induction?

A

Reactive airway disease
Hypovolemia or hypotensive
Sepsis

22
Q

When can ketamine be a poor choice for induction?

A

Ischemic heart disease as catecholamine release can lead to increased myocardial O2 demand and worsening ischemia

23
Q

What makes ketamine good for awake laryngoscopy?

A

Preserves airway reflexes

24
Q

How does Ketamine affect ICP?

A

Increases ICP from catecholamine surge, but also increases MAP => increased CPP
Growing evidence towards ketamine being safe in ICP pts

25
Q

Ketamine is contraindicated in what patients?

A

Pregnant women

26
Q

When can ketamine lead to myocardial depression?

A

In pts who are catecholamine depleted

27
Q

What are two negative side effects of Ketamine on the airway that can make intubation difficult?

A 
Increased secretions (can pre-treat with atropine or glycopyrrolate)
Laryngospasm
28
Q

Who is more likely to have an emergence reaction with ketamine? How is it treated?

A

Adults are more likely than kids

Treat with Benzos

29
Q

What is the dose for propofol?
Onset?
Duration?

A

1.5mg/kg
Onset ~30sec
lasts 5–10 minutes

30
Q

What is the effect of propofol on ICP?

A

Decreases ICP and decreases cerebral metabolism

But also decreases CPP

31
Q

How does propofol affect hemodynamics?

A

decreased BP from vasodilation and myocardial depression

32
Q

Who requires particular caution when using propofol for induction?

A

Anyone sensitive to hemodynamic changes: Elderly, debilitated, ASA class III/IV, or already with hemodynamic instability

33
Q

What patients are best for use of propofol induciton?

A

Stable patients
It is the drug of choice in pregnancy
Also good for reactive airway disease behind ketamine

34
Q

How and when should propofol dosing be modified?

A

Decrease by 1/2 or 1/3 if hemodynamic instability or elderly

35
Q

What are benzos the best drugs for?

A

Amnesia and sedation

36
Q

Why are benzos not a good option for induction?

A

Slow onset

37
Q

What dosing of versed is used for induction?

A

0.2–0.3mg/kg
Onset 60–90 sec
Lasts 15–30 minutes

38
Q

Benzos are contraindicated in which patients?

A

Pregnancy

39
Q

Benzos are not great for induction, but are great for what?

A

Procedural sedation

40
Q

What are the major downsides to each induction agent?

A

Etomidate: adrenal suppression
Ketamine: catecholamine surge, bronchial secretions, laryngospasm, emergence
Propofol: hypotension
Versed: slow onset

41
Q

Which induction agent is best for sepsis?

A

Ketamine first, then etomidate

42
Q

Which induction agent is best for pregnancy?

A

Propofol

43
Q

Which induction agents are contraindicated in pregnancy?

A

Ketamine and Versed

44
Q

Which induction agents are best for reactive airway disease?

A

Ketamine and propofol

45
Q

Which induction agent has the least effects on hemodynamics?

A

Etomidate

46
Q

Which induction agent is best for hemodynamic compromise?

A

Ketamine

47
Q

Which agent is best for ICP?

A

Etomidate

48
Q

How is laryngospasm managed?

A

1) Jaw thrust at laryngospasm notch and BVM with PEEP valve and 100% O2
2) Deepen sedation with propofol 0.5mg/kg if you have time
3) Succinylcholine and intubation

Emergency Airway Management (1 decks)

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