Erin's Pharm Exam 1; preop Flashcards
1
Q
Drug effect relates to ____
A
number of bound receptors
2
Q
Agonists bind through three types of bonds
A
ion, hydrogen, van der waals
and covalent (some do this but we dont like it because we want reversible bonds)
3
Q
How does competitive antagonism shift the dose response curve?
A
Shift dose response curves to the right
4
Q
Increasing amounts of this progressively inhibits the agonist
A
Competitive antagonism
5
Q
Non-competitive antagonism
A
Even high concentrations of the agonist can not cause the agonist effect
6
Q
Inverse agonist drugs (6)
A
LMNCPP
Loratadine, metoprolol, naloxone, cetirizine, prazosin, propanolol
7
Q
This type of agonists causes less response than the agonist even at supramaximal doses
A
Partial agonist
8
Q
Inverse agonist
A
compete for the same site as the agonist but produce the opposite effect; were categorized as agonists
9
Q
Does the number of receptors stay the same?
A
No! It can increase or decrease depending on age, disease state, comorbidity, drug therapy, etc.
10
Q
What are 4 examples of the number of receptors changing?
A
-Tachyphylaxis
-Albuterol treatment for asthma (down regulation of receptors due to repetition)
-Pheochromocytoma (decreased beta receptors in response to catecholamines)
-Ephedrine
11
Q
How are receptor types classified?
A
By location!
12
Q
Receptor locations (3)
A
-Lipid bilayer
-Intracellular proteins
-Circulating proteins
13
Q
This receptor location is common for anesthesia drugs, opioids, benzos, beta blockers, catecholamines and NMBD (B-BACON)
A
Lipid bilayer
14
Q
This receptor location is common for insulin, steroids and milrinone (SIM)
A
intracellular proteins
15
Q
This receptor location is common for anticoagulants to bind to
A
circulating proteins
16
Q
What the body does to the drug
A
pharmacokinetics (ADME)
17
Q
What type of drugs bind primarily to albumin?
A
acidic drugs
18
Q
What do alkalotic drugs primarily bind to?
A
Alpha 1-acid glycoprotein
19
Q
What do you call it when only “free” (unbound) drugs can cross cell membranes?
A
distribution
20
Q
What do you call it when only a free drug can determine concentration available to receptor?
A
Potency
21
Q
What can cause decreased plasma proteins?
A
age, hepatic disease, renal failure, pregnancy
22
Q
Drugs that are plasma protein bound ____% or greater can be impacted by abnormal plasma protein concentration
A
90
23
Q
If a normal free fraction of a drug is 2% and we lose 50% of proteins, then the free fraction of drugs is __%
A
4%
24
Q
This drug is highly bound to plasma proteins and has a small volume of distribution
A
warfarin
25
These two drugs have poor protein binding and they are lipophilic which causes them to have a big volume of distribution
thiopental, diazepam
26
What does metabolism convert?
Converts active, lipid soluble drugs into water soluble things (and the metabolites are usually inactive)
27
Examples of drugs that have active metabolites
Diazepam, propanolol, morphine (2 active) and prodrugs such as codeine
28
How are drugs metabolized in plasma?
Hoffman elimination and ester hydrolysis
29
How are drugs metabolized in the liver?
Hepatic microsomal enzymes
30
What does phase I metabolism pathway do?
It increases polarity and prepares for phase II reactions
31
This is where you lose electrons
oxidation
32
What catalyzes oxidation?
CYP450
33
This process removes oxygen or adds hydrogen molecules
reduction
34
What does phase II metabolism do?
Covalently link with a highly polar molecule to become water soluble; conjugation
35
This phase and cytochrome metabolizes >50% of drugs (opiods, benzos, LA, immunosuppressants, antihistamines)
CYP450 Phase I
36
What does induction to an enzyme do?
Example?
Increases the amount of an enzyme
Phenobarbital induces enzymes which increases the metabolism of drugs.
37
What does inhibition to an enzyme do?
Example?
Decreases the activity of enzyme
Grapefruit juice increases the concentration of drugs/toxicity levels
38
For most anesthetic drugs clearance is ____
constant (first order kinetics)
39
Elimination half time
time necessary to eliminate 50% of the drug from plasma after bolus dose
40
Context sensitive half time
Time to a 50% decrease after infusion discontinued
41
Context sensitive half time ______ the longer the infusion increases due to the accumulation in peripheral tissues
increases
42
Are barbs weak acids or bases?
acids
43
LA and opiods are ____ bases
weak
44
Acids are ionized in an ____ pH
alkaline
45
Bases are ionized in an ___ pH
acidic
46
When the pH and PK are identical......
50% of the drug is ionized and 50% of the drug is non ionized
47
pH < PK
Protonated;
Acids unionized
Bases ionized
48
pH > PK
Unprotonated
Acids ionized
Bases unionized
49
How to write ionization for an acid
PK after PH
50
How to write ionization for a weak base
PK before PH
51
What is the time to drug effect (relative potency)?
The lag time between administration (plasma concentration) and effect
52
Therapeutic index
Ratio between LD50/ED50
53
Enantiomers
chemically identical, mirror images, can not be superimposed
54
Name for an enantiomer that has rotation of light in solution to the right
Dextrorotatory
55
Name for an enantiomer that has rotation of light in solution to the left
Levorotatory
56
What fraction of drugs are racemic
1/3
57
Xoponex is an enantiomer of
albuterol
58
Cisatracurium, the isomer of atracurium, lacks ____ effects
histamine effects
59
This induces calm or sleep
Sedatives
60
Hypnotics
induces hypnosis
61
How does sleep share similarities with anesthesia?
It inhibits the thalamic and mid brain RAS and reversibly inhibits CNS
62
These two things relate to EEG activity
CBF and CMRO2
63
With hypontic drugs, the BIS change correlated with movement. Is this the same for a high dose narcotic?
No, with a high dose narcotic there is less correlation between BIS and movement
64
BIS studies showed that no patient with BIS ____ was conscious
<58
65
What is the suppression ratio on a BIS?
It tells you how much of the time the BIS has been zero. Your suppression ratio would never have a number
66
BIS #0
No brain wave activity, brain dead
67
BIS #100
Awake and alert
68
BIS #40-60
Ideal number for no recall
69
These synergistic drugs lower BIS
hypnotics, volatiles, NMBD, opiods
70
These drugs can increase BIS numbers and confuse picture even though patient is perfectly amnestic
Ketamine and epinephrine (sympathomimetics)
71
Benzos do 5 things:
(AAA-SS)
1. Anxiolytics
2. Anterograde amnesia
3. anticonvulsant
4. Sedation
5. Spinal cord mediated skeletal muscle relaxation
72
What is the only thing that can cause retrograde amnesia?
ECT
73
With benzos, anterograde amnesia lasts ____ than sedative effects
longer
74
Why have benzos replaced barbiturates?
Barbs have more complications with tolerance, more side effects, and they don't induce enzymes to be metabolized as quickly
75
Do benzos induce hepatic microsomal enzymes like barbs?
No
76
Which benzo is used in periop due to its prompt recovery?
Versed! Quick on and quick off.
77
Why are diazepam and lorazepam more attractive for sedation post op?
They have a much greater 1/2 time than versed
78
What is the principal inhibitor neurotransmitter in CNS?
GABA
79
This causes hyper polarization of post synaptic membranes and enhanced opening of Cl- channels
GABA
80
GABA alpha 1 subunit properties
sedative, amnestic, anticonvulsant
81
Most abundant GABA subunit
alpha1
82
GABA alpha 2 subunit properties
anxiolytics, skeletal muscle relaxation
83
All benzos are _____ lipid soluble and _____ protein bound
highly, highly
84
Do benzos cross BBB?
Yes
85
Which benzo does not produce an isoelectric state>
Versed; it has a ceiling
86
What things are synergistic with benzos?
Alcohol, injected anesthetics, opiods, alpha 2 agonists, inhaled anesthetics, etomidate
87
What is the purpose of the imidazole ring in versed
Stabilizes the structure and allows for rapid metabolism
88
This benzo is 2-3x as potent as valium
versed (midazolam)
89
Which benzo has a greater affinity for its receptor, valium or versed?
versed
90
With versed, which effect lasts longer, amnesia or sedation?
amnesia > sedation
91
Versed is water soluble, what does this mean for the formulation?
it does not need a solvent added to it! That's why it does not sting as bad
92
Explain ring theory versed
The ring opening makes it inactive and shutting makes it active!
93
<3.5 pH the versed ring is ____ which means it is ____ soluble and ______ (active or inactive?)
open, water, protonated / inactive
94
>4.0 pH the versed ring is ____ which means it is ____ soluble and ______ (active or inactive?)
closed, lipid, active/unprotonated
95
Versed onset
1-2 minutes
96
Versed plasma binding
96-98%; extensively bound
97
Versed peak effect time
5 minutes
98
Why does versed have a relatively short duration?
lipid solubility
99
Versed E 1/2 time
2 hours
50% of it will be gone from plasma in 2 hours! Doubled in the elderly.
100
Versed VD
1-1.5L/kg (LARGE)
101
Why does versed have a larger VD in morbidly obese patients?
It is lipid soluble and has more fat it can go into
102
What enzyme metabolizes versed?
CYP3A4
103
Does versed have an active metabolite?
Yes! 1-hydroxymidazolam
This has 1/2 the activity of the parent
104
Drugs that cause inhibition of P450 enzymes and decreased BZD metabolism
Fentanyl
Antifungals
CCB
Erythromycin
Tagamet (Cimetidine)
(FACET)
105
Versed has a clearance that is ___ times faster than lorazepam and ____ times faster than diazepam
5X / 10X
106
How does versed impact CMRO2 and CBF?
The more I give, the more decreased they get - dose related
107
How does versed impact the vasomotor response to CO2?
Versed preserves this ability
108
What is the vasomotor response to CO2?
When CO2 goes up, it dilates
When CO2 goes down, it vasoconstricts
109
How does versed impact ICP?
it doesn't! Good for induction with neuro pathology
110
How effective is versed as an anticonvulsant?
It is a potent anticonvulsant (even in status!)
111
3 pulmonary impacts of Versed
-Dose dependent decrease in ventilation (esp with COPD)
-Depresses swallowing reflex
-Decreases upper airway activity
AKA we increase pt risk for aspiration!!!!
112
How does versed impact the BP/HR response to intubation?
It does NOT inhibit it; HR and BP will still spike during intubation if you only give versed
113
Sedation dosing VERSED in kids
0.25-0.5 mg/kg oral
114
VERSED in kids peak effect time
20-30 minutes
115
Sedation dosing VERSED in adults
1-5 mg IV
116
VERSED in adults peak effect time
5 minutes
117
INDUCTION dose VERSED
0.1-0.2 mg/kg IV over 30-60 seconds
118
Why do we precede versed induction with an opiod?
It picks up the speed of induction
119
If I want to precede my versed induction with fentanyl, how much will I give?
Fentanyl 50-100 mcg
120
What drug do you experience emergent excitement with?
Ketamine
121
POST OP SEDATION dose of VERSED
1-7 mg/hr IV
122
Issue with versed for post op sedation?
-Markedly delayed awakening due to active metabolite accumulating.
-Immune/T cell effects so issues with healing if you leave them on a drip for too long
123
Valium has a ____ duration of action in comparison to midazolam
prolonged
124
Is valium lipid soluble?
Yes, all benzos are highly lipid soluble
125
Is valium soluble in water?
NO! Have to add a propylene glycol to it causing painful injection
126
Valium onset
1-5 minutes
127
Valium E 1/2 time
Why is it so long?
20-40 hours
It is extensively protein bound
128
Compare the dissociation from GABA a in lorazepam vs. valium
Valium dissociates from GABA faster than lorazepam. So it has a shorter duration of action but a longer elimination half time. It is around longer, but not on the receptor for as long.
129
What enzyme metabolizes valium?
CYP3A
130
Valium active metabolites and their issues
Desmethyldiazepam and oxazepam
They are nearly as potent as diazepam and we see a return of drowsiness 6-8 hours later
131
Dose for valium as an anticonvulsant
0.1 mg/kg IV
132
Can valium produce an isoelectric EEG?
yes
133
Pulmonary effects of valium
Minimal effects on ventilation!
-Slight vT decrease
-After 0.2 mg/kg IV we see an increase in PaCO2
134
Why was valium great for cardiac surgery induction?
It minimally decreases BP, CO and SVR **even with induction doses!
Unchanged even with addition of nitrous.
135
Valium effects on the neuromuscular system
Causes spinal cord inhibition which is relaxation at the spinal cord level; does NOT cause NMJ effects so NO paralysis
136
INDUCTION dose VALIUM
0.5-1 mg/kg IV
137
In which patient populations would we decrease the valium induction dose by 25-50%
Elderly, liver disease, presence of opiods
138
Ativan resembles _____ however, Ativan has an ____ Chloride atom
Oxazepam (serax), extra chloride atom
139
Compared to versed and valium, how potent is Ativan as a sedative and amnestic?
more potent!
We can give a smaller dose and get a greater effect.
140
Is Ativan soluble in water? What does this mean for its formulation?
NO! It requires a solvent such as polyethylene glycol and burns when given IV
141
Why does Ativan have a slower onset of action compared to valium and versed?
It is not quite as lipid soluble; slower entry into CNS
142
Why does Ativan have a slower metabolic clearance compared to valium and versed?
It has lower lipid solubility; gets across bilayer and to effector site slower and comes back across lipid bilayer into blood slower as well
143
Ativan peak effect for IV dose
20-30 minutes
**4-6x longer than versed
144
E 1/2 time Ativan
14 hours!
145
Does Ativan have active metabolites? why or why not?
NO. It is conjugated into inactive metabolites via glucuronidation
146
Why is Ativan a good choice for liver disease patients?
It is not entirely dependent upon hepatic enzymes for metabolism! It can directly conjugate itself to be metabolized
147
Ativan dose
1-4 mg IV
148
What type of antagonist is Romazicon?
Competitive antagonist with a high affinity for BZD receptor
149
Why do you have to repeat doses of romazicon?
The sedative itself outlasts the effect of the romazicon; repeat doses until benzo is out of the system
150
Romazicon dose
Max dose?
Initial: 0.2 mg IV; titrated to consciousness.
Repeat: 0.1 mg q1 minute to a total of 1mg total
Give until you get the LOC you want or a man of 1 mg
151
Romazicon can result in reversal within __ minutes
2
152
What dosage range of romazicon is used to abolish therapeutic dose?
0.5-1 mg
153
Duration of flumazenil
30-60 minutes
154
Flumazenil gtt dose
0.1-0.4 mg/hr
155
Flumazenil side effects
None really, except for reversing chronic anxiety or seizure meds
156
Endogenous histamines
basophils and mast cells
157
What does histamine induce?
Contraction of smooth muscle in airways
Secretion of acid in stomach
Release of neurotransmitters in the CNS (ACh, Norepi, serotonin)
158
What drugs cause drug induced histamine release?
Protamine
Atracurium
Morphine
Mivacurium
159
How to treat drug induced histamine release?
H1 and H2 antagonists
160
Effects of histamine on H1 receptor
Hyperalgesia and inflammatory pain
Allergic rhino-conjunctivitis symptoms
161
Effects of histamine on H2 receptor
Elevates CAMP (B1-like stimulation)
Increases acid/volume production
162
Effects of H1 and H2 receptor activation
Hypotension due to nitric oxide release, capillary permeability, flushing and prostacyclin release
163
Histamine receptor antagonists are what type of antagonist?
Inverse agonists
competitive, reversible
164
T/F
Histamine receptor antagonists do not prevent the release of histamine but responses of the body to histamine
True
165
Where are H1 receptors located?
Airway smooth muscle, cardiac endothelium and vestibular system
166
H1 receptor antagonists side effects
-blurred vision
-URINARY RETENTION
-dry mouth
-DROWSINESS (1st gen)
167
H1 receptor antagonist drugs; 1st gen
Benadryl, promethazine (phenagren)
168
H1 receptor antagonist drugs; 2nd gen
Cetirizine (Zyrtec) and Loratadine (Claritin)
169
Benadryl dose
25-50 mg IV
170
Benadryl E 1/2 time
7-12 hours
171
What reflex does Benadryl *maybe* inhibit?
Oculi-emetric reflex
172
Promethazine (phenergan) E 1/2 time
9-16 hours
173
Promethazine (phenergan) dose
12.5-25 mg IV
174
Promethazine (phenergan) onset
5 minutes
175
Black box warning for Promethazine (phenergan)
-Infiltration bad; make sure you have a good IV
-Bronchospasm in kids under 2; fatal
176
What 3 things do H2 receptor antagonists do?
Decrease gastric volume, increase stomach pH and decrease hyper secretion of hydrogen ions into gastric fluid
177
What class of drugs are Cimetidine (Tagamet), ranitidine (Zantac) and famotidine (Pepcid)?
H2 receptor antagonists
178
What enzyme does cimetidine (Tagamet) inhibit
CYP450
179
What drugs are metabolized by CYP450
-Warfarin
-Phenytoin
-Lidocaine
-TCAs
-Propanolol
-Nifedipine
-Meperidine
-Diazepam
180
What H2 antagonist can cause increased levels of prolactin and impotence in men
cimetidine
181
Cimetidine (Tagamet) dose
Renal impairment dose?
150-300 mg IV
1/2 dose for renal impairment
182
This H2 antagonist weakly binds to CYP enzymes resulting in very few interactions
Ranitidine (Zantac)
183
Ranitidine (Zantac) dose
Renal dose?
50 mg diluted to 20 cc over 2 minutes
1/2 dose for renal impairment
184
This H2 antagonist does not interfere at all with CYP enzymes resulting in NO interactions
famotidine (Pepcid)
185
Most potent H2 antagonist? with a half life of 2.5-4 hours
pepcid
186
What electrolyte does Pepcid interfere with?
Phosphate absorption; hypophosphatemia
187
Famotidine (Pepcid) dose
Renal dose?
20 mg IV
1/2 dose
188
How do PPIs bind to pumps?
They irreversibly bind to acid secretion pumps! They only inhibit the currently functioning pumps not the ones that have not been made yet! Our body constantly makes proton pumps that's why you have to continue the drug
189
Are PPIs better for acute or preemptive use?
Preemptive!
190
PPIs have been associated with...
Bone fx, SLE, nephritis, C-diff and B12 / mag deficiency
191
PPIs block the enzyme that ____ clopidogrel
activates
192
How does PPIs impact warfarin?
They inhibit the metabolism of warfarin; our INR will be high
193
Prilosec (omeprazole) dose
40 mg in 100 cc NS over 30 minutes; piggy back not push.
PO must be >3 hours prior
194
Is Prilosec a prodrug or active drug?
Prodrug
195
What % max inhibition will you see with Prilosec?
66
196
What side effects of omeprazole indicate it crosses the BBB?
HA, agitation, confusion
197
Protonix 1/2 time compared to prilosec
Protonix has a longer E 1/2 time compared to prilosec
198
It only takes proton pump inhibitors __ hr(s) to decrease gastric volume and raise pH. It takes ___ days to inhibit ALL functioning proton pumps
1 hour, 5 days
199
Protonix dose
40 mg in 100 mL over 2-15 minutes
200
PPIs are the DOC for these 2 things
GERD and gastroduodenal ulcers
201
If we have concerns for aspiration will we give a. H2 antagonist or a PPI?
H2 antagonist because they work faster
202
Particulate antacids are ___ or ___ based
aluminum or mag
203
Why do we not give particulate antacids?
More dangerous to aspirate on the particle
204
Non particulate antacids have what bases?
Sodium, carbonate, citrate and bicarbonate
205
What is a non-particulate antacid?
Sodium citrate / bicitra
206
This antacid is given to all c section ladies
BICITRA; uterus being manipulated makes mom nauseous! This drug decreases risk for aspiration pneumonia! Not the risk for aspiration
207
How long does it take for bicitra to kick in? How long does it take for it to lose effectiveness?
immediately kicks in, loses effectiveness in 30-60 minutes
208
Bicitra dose
15-30 mL PO
209
Who is considered full stomachs
Trauma pt, pregnant ladies 12-16 weeks or greater
210
How do dopamine blockers help with full stomach?
They are pro kinetic (stimulate GI motility) and work on getting stuff out of the stomach so there is nothing left to aspirate
211
Dopamine blockers effects on GI system (3)
-Increases lower esophageal sphincter tone
-Stimulates peristalsis
-Relaxes pylorus and duodenum
212
What are the three dopamine blockers?
Which one is off market?
Reglan, droperiodol and Domperidone
-Domperiodone taken off market due to dysrhythmias and sudden death
213
Do dopamine blockers alter gastric pH?
no, they just move things forward so you can not throw up
214
Bad effects of dopamine blockers
-Extrapyramidal reactions (crosses BBB easy)
-Orthostatic hypotension
-Some effects on chemoreceptor trigger zone
*can not give to pt with dopamine depletion / inhibition (Parkinson's and Huntingtons)*
215
This drug is cleard by the FDA for gastroparesis
Reglan (metoclopramide)
216
Side effects of reglan:
-Abd cramps (due to squeezing of sphincter and increased propulsion of stomach)
-Muscle spasms
-Sedation or extrapyramidal symptoms (crosses BBB)
-Neuroleptic malignant syndrome
-decreases plasma cholinesterase levels
217
Why does succ last longer when you administer reglan to a patient?
Reglan decreases plasma cholinesterase level which slows the metabolism of succ
218
Reglan dose
Timing
10-20 mg IV over 3-5 minutes
15-30 min prior to induction
219
Does domperidone cross the BBB?
no
220
This dopamine blocker is related to haldol
Droperidol (inapsine)
221
This dopamine 2 antagonist was developed for schizophrenia and psychosis
droperidol (inapsine)
222
Droperidol risk factors / side effects and black box warnings
-Extrapyramidal symptoms
-Neuroleptic malignant syndrome
-Avoid other CNS depressants (such as general anesthetics)
-Black box: prolonged QT and torsades with higher doses
-LOTS of serious drug interactions (amio, diuretics, sotalol, CCBS)
223
This drug is more effective than reglan and equally effective to 4mg zofran but not often used due to the crazy side effects
droperidol
224
Droperidol dose
0.625-1.25 mg IV
225
Where is serotonin released from?
chromaffin cells in small intestine
226
What receptor does serotonin hit that stimulates vagal afferents and causes vomiting?
5HT3
227
Where are serotonin receptors found? Which ones do we care about?
EVERYWHERE! we are concerned with the ones in the brain and GI tract
228
Can I use a 5HT3 antagonist for motion sickness?
No
229
Name the 3 5HT3 antagonists
-Zofran
-Granisetron (kytril)
-Dolasetron (Anzemet)
230
This is the first 5-HT3 antagonist
Zofran
231
How does zofran impact:
-Dopamine, histamine, adrenergic and cholinergic activity?
-CNS
-QT interval
It doesn't
No CNS effects
SLIGHT Prolongation of QT interval
232
Plasma 1/2 life of Zofran
4 hours
233
Zofran dose
4-8 mg IV
234
We do not know the MOA behind corticosteroid for n/v but we think it has to do with these two things:
1. controlling endorphin release
2. anti inflammatory, less post op pain, less opiods administered
235
Name the corticosteroid we talked about
Decadron (dexmethasone)
236
Decadron has a delay in onset of ___ hours.
What does this mean for you?
2 hours
If you have a 6 hour case, give it 4 hours into the operation
If you have a 2 hour case, give it as soon as the case starts
237
Efficacy of decadron persists for ___ hours
24 hours
238
We usually time decadron 2 hours before the end of a case. What is the exception to this rule?
Difficult intubations! We want to prevent airway swelling because swelling will interfere with the patient's ability to maintain their own airway.. then we would not be able to extubate them
239
Decadron side effects?
Hyperglycemia (not a concern with only one dose)
Perineal burning / itching
240
Decadron dose for N/v
4 or 8 mg
241
Decadron dose for airway swelling concerns
12-20 mg
242
How does scopolamine work at its receptor?
It is a competitive antagonist of ACH
243
Scopolamine peak concentration
8-24 hours
244
Apply a scopolamine patch __ hours preop
4 hours
245
Side effects of scopolamine
dilated pupil, drowsiness
246
Scopolamine dose
1 patch for 24-72 hours post auricular
247
Scopolamine priming dose?
140 mcg then 1.5 mg over next 72 hours
248
How potent is scopolamine at being an antisialagogue?
Very! it dries up spit
249
Explain how beta receptor agonists relax the airway
-Stimulatory G proteins
-activate cAMP
-This decreases Ca entry
-this decreases contractile protein sensitivity to calcium
-This results in relaxation
250
The side effects of beta agonists are similar to...
what catecholamine release causes
251
Beta agonist side effects
tremor, tachycardia, transient decrease in arterial oxygenation, hyperglycemia
252
We can see a 15% increase in FEV1 with beta agonists after ___ minutes
6 minutes (with 2 puffs)
253
Explain delivery of inhaled SABA
Discharge inhaler (2 puffs) while taking a slow, deep breath over 5-6 seconds.
Hold breath at max inspiration for 5-6 seconds
254
Diethyl ether was made from
sulfuric acid and etyhl alcohol
255
Anesthesia is a drug induced loss of ____
consciousness
256
Most recent anesthethic gas
Sevoflurane
