Day 3-Systemic Health Considerations

Question 1

Name that ASA status: 1 flight of stairs or 2 level city blocks without distress = SOB, undue fatigue, chest pain…..Anesthetic? Vasoconst?

Answer 1

ASA I…Yes…Yes

Question 2

Name that ASA status: Must rest at top of flight of stairs 􏰀Treatable with consideration for treatment modification (Type II Diabetes, Asthma,Epilepsy, and high BP (140-159/90) all well controlled….Anesthetic? Vasocon?

Answer 2

ASA II….Yes…Yes

Question 3

Name that ASA status: Severe systemic disease that limits activity, but is not incapacitating..Must stop to rest before reaching top of the flight of stairs Treatable, with SERIOUS consideration for treatment modification….Anesthetic?….Vasocon?

Answer 3

ASA III….Yes…Yes (limit 0.04 epi)

Question 4

What ASA status is a pt with an MI MORE THAN 6 months ago?

Answer 4

ASA III (ASA IV if

Question 5

What ASA status is a Pt with STABLE angina?

Answer 5

ASA III

Question 6

What ASA Status is a Pt with a BP of 180-199/105-114?

Answer 6

ASA IIIb (WOW)

Question 7

Name that ASA status: Incapacitating systemic disease that is a constant threat to the patient’s life….Anesthetic? Vasocon?

Answer 7

ASA IV…Yes….NO (if status is based on CVD)

Question 8

Name that ASA status: Moribund patient, not expected to survive 24 hours Hospitalized, “no code“- DNR…Anesthetic? Vasocon?

Answer 8

ASA V…Yes (palliative)…NO (if CVD)

Question 9

What are the three categories of CNS drugs that we need to be careful for interactions with LA? (Thee three A’s) Whats the game plan?

Answer 9

Anticonvulsants, Antipsychotics, Antidepressants….just stay away from higher doses

Question 10

What type of antidepressants can ENHANCE the CV actions of vasopressors? Which two vasopressors have the most interaction? By how much?

Answer 10

TriCyclic’s….Levonordephrine and Norepinephrine have a 5-10x enhancement of the Tricyclics…only 2x with epi!

Question 11

Which drug class that WE may Rx for anxiety has interaction with the anesthetic?

Answer 11

BENZOs! (limit the LA dose)

Question 12

Which class of drugs are we concerned about keeping the STRESS of LA down? What can we do to combat this?

Answer 12

Glucocorticoids….risk of adrenal crisis c/o no endogenous stress response….give N2O or use IV sedation

Question 13

What is the ONLY H2 receptor blocker (heartburn/ulcers) that has interactions with lido?

Answer 13

TAG-A-MET….it competes with lido for biotransformation and leaves lido in the system longer

Question 14

Combining LA agents together may be done safely… Toxicity risk is ______

Answer 14

additive

Question 15

Sedation with _______ analgesics may increase risk of developing LA overdose…Risk is greater in CHILDREN 􏰀 Minimize dose of LA

Answer 15

OPIOID

Question 16

Who is at risk for vasopressor interaction with beta blockers? (like what TYPE of beta blockers)…..What is the risk?

Answer 16

NON-selective beta blockers….risk is having a hypertensive event and secondary bradycardia

Question 17

How do I tell if a Pt is on a NON-selective Beta blocker or a cardio-selective beta blocker? What is the only exception?

Answer 17

A-M = Cardio-selective…..N-Z= Non-selective…LAB-ET-A-LOL is the exception…its NON-selective

Question 18

Increased risk for ________ when patients receiving certain ________ general anesthetics (eg. Halothane) are given ________ (LA or Epi?)

Answer 18

arrhythmias…..halogenated…EPI

Question 19

What are the two Street drugs that are going to cause SNS effects when paired with EPI? How long do we need to wait? is this a relative or absolute contraindication?

Answer 19

Cocaine and Methamphetamine….wait 24hrs…ABSOLUTE contraindication

Question 20

What can EtOH use do to LA?

Answer 20

Decrease its effectiveness..also can cause LA OD

Question 21

CONGESTIVE HEART FAILURE: Pts may be on ________ (_____) which when mixed with EPI can cause arrythmias

Answer 21

cardiac glycosides (digoxin)

Question 22

CONGESTIVE HEART FAILURE: What other organ do we need to be concerned with in these Pt when considering clearance of LA?

Answer 22

KIDNEY function

Question 23

CONGESTIVE HEART FAILURE: If a pt is ASA IV SYMPTOMATIC, then dental Tx is ________

Answer 23

contraindicated

Question 24

Since Sickle cell anemia has “_____” episodes we will not do dental Tx then…which part of our LA do we need to consider the most?

Answer 24

crisis…LIMIT the vasoconstrictors!! (plain drugs PREFERRED!)

Question 25

HEY GOOD NEWS!!! LA in therapeutic dosages rarely affects _______ system

Answer 25

RESPIRATORY

Question 26

If the rare occurrence of a respiratory event is triggered with LA, what is most likely the source?

Answer 26

Sulfide allergy

Question 27

Decreased liver function = lowest _____, least concentration

Answer 27

dose

Question 28

Diabetes ________ opposes insulin….Assess cardiac co-morbidities

Answer 28

Epi

Question 29

HYPERthyroidism…Thyrotoxic crisis….________ raises risk for “thyroid STORM”….________ contraindication if uncontrolled

Answer 29

Epinephrine…. ABSOLUTE

Question 30

Hypothyroidism… Generally OK, but more sensitive to ____

depressants – minimize LA dose

Answer 30

CNS

Question 31

_____________ Rare adrenal medulla tumor….Secrete endogenous epinephrine…HTN, arrhythmias….Absolute contraindication to vasoconstrictor

Answer 31

Pheochromocytoma

Question 32

What are the two LAs to be aware of for Methemoglobemia? Which one is the PRIMARY?

Answer 32

Benzocaine (topical)…PRILOCAINE (topical and inject) = PRIMARY

Question 33

Methemoglobemia + THIS ANALGESIC + high dose of Prilocaine = disaster

Answer 33

acetaminophen

Question 34

WHICH LA is used for ASA III LIVER/KIDNEY DISEASE c/o its unique structure????

Answer 34

ARTICAINE (ester side chain is biotransformed in blood)

Question 35

Can a Pt be allergic to Epi?

Answer 35

NO, not a TRUE allergy

Question 36

When is the safest Trimester to give LA? When is a contraindicated time for LA in pregnancy?

Answer 36

Safest = 2nd trimester….3rd is hard for mom to metabolize the drugs