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ABSITE 2019-RM > Chapter 8: Anesthesia > Flashcards

Chapter 8: Anesthesia Flashcards

1
Q

Type of Agents that:

  • Blunt hypoxic drive
  • Caused unconsciousness, amnesia, some analgesia
  • Most have myocardial depression, increase CBF, decrease RBF
A

Inhalational agent

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2
Q

Smallest concentration of inhalation agent at which 50% of patients will not move with incision

A

MAC (minimum alveolar concentration)

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3
Q

Inhalational agent that is Fast, minimal myocardial depression; tremors at induction

A

Nitrous oxide (NO2)

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4
Q

Inhalational agent that is-
Slow onset / offset, highest degree of cardiac depression and arrhythmias
- Least pungent, which is good for children for induction

A

Halothane

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5
Q

Manifestations of halothane hepatitis

A

Fever, eosinophilia, jaundice, increased LFTs

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6
Q

Inhalational Agent that is -

Fast, less laryngospasm and less pungent; good for mask induction

A

Sevoflurane

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7
Q

Inhalational agent
-Good for neurosurgery (lowers brain oxygen consumption; no increase in ICP) (recent studies show no clear difference between all these agents regarding ICP)

A

Isoflurane

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8
Q

Inhalational agent thatCan cause seizures

A

Enflurane

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9
Q

IV anesthetic that is:

  • (Barbiturate) fast acting
  • Side effects: decrease CBF and metabolic rate, decrease blood pressure
A

Sodium thiopental

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10
Q

IV anesthetic

  • Very rapid distribution and on/off; amnesia; sedative
  • Not an analgesic
  • Metabolized in liver and by plasma cholinesterase’s
  • Side effects: hypotension, cardiac and respiratory depression
A

Propofol

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11
Q

IV anesthetic
Dissociation of thalamic / limbic systems; places patient in a cataleptic state (amnesia, analgesia).
- No respiratory depression
- Contraindicated in patients with head injury
-known for causing hypersecretions
- Good for children

A

Ketamine

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12
Q

IV anesthetic
Side effects: hallucinations, cathetcholamine release (increase CO2, tachycardia), increased airway secretions and increased cerebral blood flow

A

Ketamine

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13
Q

IV anesthetic

  • Fewer hemodynamic changes; fast acting
  • Continuous infusions can lead to adrenocortical suppression (this is why its no longer used as a drip in ICU)
A

Etomidate

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14
Q

When is RSI (rapid sequence intubation) indicated?

A
  • Recent oral intake
  • GERD
  • Delayed gastric emptying
  • Pregnancy
  • Bowel obstruction
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15
Q

Last muscle to go down and first muscle to recover from paralytics

A

Diaphragm

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16
Q

First to go down and last to recover from paralytics

A

Neck muscles and face

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17
Q

Only one is succinylcholine; depolarizes neuromuscular junction

A

Depolarizing agents

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18
Q
  • Caused by a defect in calcium metabolism

- Calcium released from sarcoplasmic reticulum causes muscle excitation: contraction syndrome

A

Malignant hyperthermia

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19
Q

First sign of malignant hyperthermia

A

Increased end-tidal CO2

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20
Q

Side effects: first sign is increased end-tidal CO2, then fever, tachycardia, rigidity, acidosis, hyperkalemia

A

Malignant hyperthermia

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21
Q

Malignant hyperthermia; tx dosing

A

Tx: dantrolene (10mg/kg) inhibits calcium release and decouples excitation; cooling blankets, HCO3, glucose, supportive care

give 2.5mg/kg repeatedly until symptoms go away for maximum of 10-20mg; if does not resolve by then then diagnosis is unlikely

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22
Q

When do you NOT use succinylcholine?

A 
Severe burns.
Neurologic injury.
Neuromuscular disorders.
Spinal cord injury. 
Massive trauma.
Acute renal failure.
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23
Q

Complications of succinylcholine

A
  • Malignant hyperthermia
  • Hyperkalemia
  • Open-angle glaucoma
  • Atypical pseudocholinesterases
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24
Q

Type of agents that

  • Inhibits neuromuscular junction by competing with acetylcholine
  • Can get prolongation of these agents with myasthenia gravis
A

Nondepolarizing agents

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25
Q

Non-depolarizer neuromuscular blocker

  • Undergoes Hoffman degradation
  • Can be used in liver and renal failure
  • Histamine release
A

Cis-atracurium

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26
Q

Non-depolarizer neuromuscular blocker: Fast, intermediate duration; hepatic metabolism

A

Rocuronium

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27
Q

Non-depolarizer neuromuscular blocker:

  • Slow acting, long-lasting; renal metabolism
  • Most common side effect: tachycardia
A

Pancuronium

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28
Q

Blocks acetylcholinesterase, increasing acetylcholine

A

Neostigmine

Edrophonium

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29
Q

Should be with neostigmine or edrophonium to counteract effects of generalized acetylcholine overdose

A

Atropine or glycopyrrolate

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30
Q

Work by increasing action potential threshold, preventing Na influx.

A

Local anesthestics

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31
Q

Why are infected tissues difficult to anesthetize with local anesthetics?

A

Secondary to acidosis.

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32
Q

Length of action of local anesthetics: greatest to least

A

Bupivacaine > lidocaine > procaine

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33
Q

Side effects of local anesthetics

A

Tremors
Seizures
Tinnitus
Arrhythmias (CNS symptoms occur before cardiac)

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34
Q

What does addition of epinephrine to local anesthetics allow?

A

Allows higher doses to be used, stays locally

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35
Q

When do you not use epinephrine with local anesthetics?

A

No epi with:

Arrhythmias, unstable angina, uncontrolled hypertension, poor collaterals (penis and ear), uteroplacental insufficiency

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36
Q

Two different genres of local anesthetics

A

Amides (all have “i” in first part of their name)

Esters

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37
Q

Allergic reactions: amides vs esters

A

Esters: increased allergic reactions due to PABA analogue

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38
Q

Metabolism: opioids

A

Metabolized by the liver and excreted via kidney

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39
Q

What can narcotics cause precipitate in patients on MAOIS?

A

Hyperpyrexic coma

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40
Q

Analgesia, euphoria, respiratory depression, miosis, constipation, histamine release (causes hypotension), decreased cough

A

Morphine

41
Q

Analgesia, euphoria, respiratory depression, miosis, tremors, fasciculations, convulsions

A

Demerol

42
Q

Does demerol cause histamine release?

A

NO.

43
Q

Why avoid demerol in patients with renal failure?

A

Can cause seizures (buildup of normeperidine analogues)

44
Q

simulates morphine, less euphoria

A

Methadone

45
Q

Fast acting; 80x strength of morphine (does not cross-react in patients with morphine allergy); no histamine release

A

Fentanyl

46
Q

Very fast acting narcotics with short half lives

A

Sufentanil and remifentanil

47
Q

Most potent narcotic

A

Sufentanil

48
Q

Anticonvulsant.
Amnesic.
Anxiolytic.
Respiratory depression.

A

Benzodiazepines

49
Q

Do benzodiazepines have pain relief?

A

No.

50
Q

Metabolism: benzos

A

Liver

51
Q

Benzo:

  • Short acting
  • Contraindicated in pregnancy
  • Crosses placenta
A

Versed (midazolam)

52
Q

Benzo:

- Intermediate acting

A

Valium (Diazepam)

53
Q

Benzo:

- Long acting

A

Ativan (lorazepam)

54
Q
  • Benzo OD
  • Competitive inhibitor
  • May cause seizures and arrhythmias
  • Contraindicated in patients with elevated ICP or status epilepticus
A

Flumazenil

55
Q

MC side effect flumazenil

A

Nausea

56
Q

Allows analgesia by sympathetic denervation.

Vasodilation.

A

Epidural anesthesia

57
Q

Epidural with morphine

A

Can cause respiratory depression

58
Q

Lidocaine in epidural

A

Decreased heart rate and blood pressure

59
Q

How can motor function be spared with epidural?

A

Dilute concentrations

60
Q

Tx: acute hypotension / bradycardia with epidural

A

Turn epidural flows down.
Fluids.
Phenylephrine.
Atropine

61
Q

Epidural level: affect cardiac accelerator nerves

A

T1-5

62
Q

Contraindications: epidural

A

Hypertrophic cardiomyopathy.

Cyanotic heart disease.

63
Q

Why h-cmp and cyanotic heart disease contraindications to epidural anesthesia?

A

Sympathetic denervation causes decreased after load, which worsens these conditions

64
Q

Injection into subarachnoid space, spread determined by baricity and patient position

A

Spinal anesthesia

65
Q

Contraindications: spinal

A

Hypertrophic cardiomyopathy.

Cyanotic heart disease.

66
Q

Caused by CSF leak after spinal / epidural.

Headache gets worse sitting up.

A

Spinal headache

67
Q

Tx: Spinal headache

A

Rest. Fluids. Caffeine. Analgesics. Blood patch to site if it persists > 24 hours.

68
Q

Associated with most postop hospital mortality

A
  1. Pre-op renal failure

2. CHF

69
Q

May have no pain or EKG changes. Can have hypotension, arrhythmias, increased filling pressures, oliguria, bradycardia.

A

Postop MI

70
Q

Patients who need cardiology workup pre-op (x13)

A

Angina. Previous MI. SOB. CHF. METs 5min. High grade heart block. Age >70. DM. Renal insufficiency. Patients undergoing major vascular surgery.

71
Q

Considered high risk surgery

A

Most aortic, major vascular, peripheral vascular surgery

72
Q

Risk: carotid endarterectomy (CEA)

A

Considered moderate risk surgery

73
Q

Biggest risk factors for post MI

A 
Age > 70.
DM.
Previous MI.
CHF.
Unstable angina.
74
Q

Best determinate of esophageal vs tracheal intubation

A

End-tidal CO2

75
Q

Intubated patient undergoing surgery with sudden transient rise in ETCO2
Dx? Tx?

A

Dx: most likely hypoventilation.
Tx: increased tidal volume or increased respiratory rate.

76
Q

Goal endotracheal tube placement

A

2cm above the carina

77
Q

Associated with lower mortality for abdominal aortic aneurysm repair and for pancreatic resection

A

Higher volume hospitals

78
Q

MC PACU complication

A

nausea and vomiting.

79
Q

Diagnosis:

pt on profofol infusion develops bradycardia, low UOP, incr cr, hyperkalemia and acidosis? Management?

A

propofol infusion syndrome

ppx with daily screening with lactate and CPK and changing propofol if >48 hrs

80
Q

protective factor for perioperative nerve injuries

A

obesity, proper positioning (although many occur even with this)

81
Q

risk factors for perioperative nerve injuries

A

low BMI, diabetic neuropathy

82
Q

EMG results after perioperative nerve injuries

A

usually normal but should be done early

83
Q

during arterial line SBP measurement where is the pressure higher: radial or aortic

A

radial ( higher as it goes more diatal, smaller and more calcified)

84
Q

why is morphine generally contraindicated in renal failure

A

morphine is only opioid that has an active metabolite which in regular pts is no problem bc its quickly excreted howver in renal pts there is a build up

85
Q

types of ventilator modes

A
  • continuous positive airway pressure (CPAP): all breaths are triggered by the patient and no additional support is provided.
  • Pressure support ventilation (PSV) allows the patient to determine the rate and volume of breaths but provides additional pressure to support a patient-triggered breath. -SIMV allows the clinician to mandate a certain number of breaths per minute at a set volume or pressure but allows the patient to breath spontaneously in between the machine-triggered breaths. It is frequently combined with PSV to provide additional pressure to support the patient-triggered breaths.
86
Q

top three likely offenders in a pt who develops acute hypersensitivity reaction during an operation

A

neuromuscular blocking agents (-oniums) -60%
latex 20%
abx 13%

87
Q

ASA designations

A
  1. healthy, nonsmoking and no or minial etoh use
  2. mild systemic disease ( HTN, smoking or social alcohol use, pregnancy, obesity)
  3. Severe systemic disease ( ESRD, COPD, alcohol dependence, MI>3 months
  4. Severe systemic disease that is a constant threat to life ( MI<3 months, recent CVA, ESRD but not regularly going)
  5. moribund not expected to survive without the operation
  6. brain dead ( organ donation)
88
Q

malignant hyperthermia genetic association

A

autosomal dominant

89
Q

malignant hyperthermia can develop as early as _____ and as late as _______

A
  1. 30 mins

2. 24 hrs

90
Q

maximum dosing of 1% lido w/ and w/o epi

A

4 mg/kg (typically 1% lido has 10 mg/ml)

7 mg/kg

91
Q

next step if a pt develops trismus (masseter muscle rigidity) after induction

A
  1. wait 20-30 seconds and should resolve
  2. persistent trismus is NOT a sign of inadequate neuromuscular blockade and should raise suspicion for malignant hyperthermia- surgery should be cancelled and pt placed in observation 24 hrs with referal for muscle bx
92
Q

main concern for pts undergoing anesthesia that have aortic stenosis

A 
avoiding hypotension ( due to concentric hypertrophy they are preload dependent)- imperative to keep them intravascularly full
-increase preload, maintain afterload (coronary filling), avoid bradycardia, or any arythmias (loss of atrial kick)
93
Q

dopamine effect on receptors depending on dose

A
  • effect on α- and β-adrenergic receptors is generally weaker than epinephrine and norepinephrine.
  • At lower doses (1 to 2 mcg/kg per minute), its predominant effect is on the dopaminergic receptors causing renal and visceral vasodilation
  • 3 to 10 mcg/kg per minute, the β1-adrenergic receptors predominate; this is most similar to the effects of dobutamine or low dose epinephrine.
  • greater than 10 mcg/kg per minute, the α1-adrenergic receptors predominate, leading to peripheral vasoconstriction; this is most similar to the effects of phenylephrine.
94
Q

pt fails to regain twitches after neuromuscular blockade; etiology? dx? tx?

A

acquired or genetic pseudocholinesterase deficiency (needed to degrade succinylcholine)

acquired -liver disease
genetic (auto recessive)
dx: decrease plasma cholinesterase enzyme activity)
supportive tx ( wait until spontanously regains muscle function)

95
Q

pseudocholinesterase deficiency affect breakdown of what drugs?

A

esters local aneshetics

cocaine

96
Q

pt is given benzocaine and develops cyanosis however O2 sats is 100%. dx and tx?

A

methhemoglobunemia

IV methiline blue

97
Q

if a pt is intubated and pretty sure in right place but capnography reads wrong. what to do? when does this happen?

A

typically in pts that have received multiple doses of epi during ALS, airway obstruction, poor pulm blood flow
confirm with endotracheal US

98
Q

what is demerol? how does it differ from morphine?

A

opioid

does not release histamine thus no hypotension

ABSITE 2019-RM (33 decks)

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