Exam 2: 24 Feb Multi-Modal and GA Flashcards
What is multi-modal anesthesia?
An anesthesia approach that combines multiple techniques to enhance pain management and reduce opioid use.
It includes aspects like preoperative care, fluid loading, short-acting agents, opioid-sparing agents, temperature management, and neuromuscular monitoring.
What is the significance of the $630.5 billion statistic in the context of pain management?
It represents the economic impact of pain in the US, highlighting the need for effective pain management strategies.
This statistic is from 2012 and reflects the growing opioid overdose crisis.
What are some non-opioid alternatives for pain management mentioned by Dr. Castillo?
- Massage
- Physical Therapy (PT)
- Occupational Therapy (OT)
- Behavioral interventions
- Non-opioid anesthesia
Other alternatives include yoga and Tai Chi.
Define opioid-free anesthesia.
An anesthetic technique that provides anesthesia and post-op pain relief without the use of opioids.
It involves using medications that block surgical and post-surgical pain.
What is the definition of pain according to the International Association for the Study of Pain?
An unpleasant sensory and emotional experience.
Pain can be classified as acute or chronic.
List the major components of pain pathways discussed in the content.
- Stimulation
- Sensation transduction
- Transmission
- Perception
- Modulation
- Response
These components are critical for understanding how pain is processed in the body.
What medication is used for post-op nausea and vomiting?
Ondansetron (Zofran)
It is often combined with Decadron for enhanced anti-nausea effects.
What role does Gabapentin play in pain management?
It acts as a structural analog of GABA, enhancing descending inhibition and reducing pain perception.
Commonly used for chronic pain syndromes and given pre-operatively.
What are the recommended dosages for Acetaminophen in pre-op settings?
1000 mg PO
Dosage can vary, but it is typically administered before surgery.
True or False: Magnesium can promote hypotension.
True
It is used for blood pressure control but must be monitored closely.
What is the maximum daily dosage for Ketorolac?
3200 mg per day
This is for IV administration over specific intervals.
What are the two types of NSAIDs mentioned?
- Non-specific NSAIDs (e.g., Ibuprofen, Naproxen)
- Cox-2 selective inhibitors (e.g., Celebrex)
Each type has different mechanisms and benefits.
Fill in the blank: The use of _______ is emphasized for opioid-sparing techniques in anesthesia.
[opioid-sparing agents]
What are the benefits of using Cox-2 inhibitors?
- Reduced gastric protection
- Less impact on hemostasis
These benefits make them preferable in specific situations.
What is a significant risk of using Lidocaine?
Toxicity if not monitored properly.
It is important for peripheral nerve blocks and regional anesthesia.
What is Decadron used for in the context of anesthesia?
Post-op nausea and vomiting, and pain management.
It may also affect blood sugar levels in diabetic patients.
How is Methadone viewed in the context of pain management?
As a potential non-opioid alternative with ongoing studies on its efficacy.
Its legalization varies by state.
What should be monitored when administering Magnesium?
Blood pressure
Magnesium can cause hypotension, requiring careful observation.
What is the initial dose of Gabapentin given to the patient preoperatively?
200 milligrams PO
Given with a sip of water prior to surgery, typically 30 minutes to an hour before.
What additional medications are commonly given in a preoperative pain management cocktail?
- Brex 100 milligrams PO
- Tylenol 1000 milligrams PO
- Pepsi 20 milligrams IV
- Zofran 4 milligrams IV
- Versa 1 milligram IV
- Decadron 4 to 10 milligrams IV
Decadron is used for pain management and to reduce postoperative nausea and vomiting.
What are some potential side effects of Gabapentin?
- Ataxia
- Vertigo
- Gastrointestinal disturbances
- Withdrawal symptoms
- Seizures
- Weight gain
These side effects can vary in severity and occurrence.
What was a limitation of the 2017 meta-analysis regarding Gabapentin?
It only included 10 randomized controlled trials with 827 patients
Typically, meta-analyses involve thousands of patients for more robust conclusions.
What is the typical protocol dose of Gabapentin for elderly patients in Naples?
200 milligrams
This is based on the established protocol for pain management.
What is the primary purpose of NSAIDs?
Analgesia, anti-inflammatory effects, and fever reduction
NSAIDs can decrease activation of peripheral nociceptors and provide preemptive analgesia.
How do NSAIDs affect gastric protection?
They can inhibit gastric protection if they affect the COX-1 pathway
This can lead to ulcerations and gastrointestinal issues.
What distinguishes COX-1 from COX-2 inhibitors?
- COX-1 is ubiquitous and responsible for gastric protection
- COX-2 is specific for inflammation and fever
COX-2 inhibitors are preferred to avoid gastrointestinal side effects.
What are some examples of non-specific NSAIDs?
- Ibuprofen
- Naproxen
- Aspirin
- Acetaminophen
These are commonly used but may lead to more side effects compared to COX-2 selective NSAIDs.
What is the peak action time for Celebrex?
3 hours
The typical dosage ranges from 200 to 400 milligrams.
What is the maximum daily dosage of acetaminophen recommended?
3000 to 4000 milligrams
Some sources suggest different maximums, hence the range.
What is the mechanism of action of acetaminophen?
Inhibits prostaglandin synthesis by inhibiting both COX-1 and COX-2
It has analgesic and antipyretic properties but lacks significant anti-inflammatory effects.
What is a relative contraindication for using Ketorolac in elderly patients?
Age over 65 years
While age can be a concern, it is not an absolute contraindication if the patient is otherwise healthy.
What can happen with the excessive use of non-specific NSAIDs?
Gastrointestinal ulceration and renal impairment
This is due to their action on COX-1 and COX-2 pathways.
What is the peak action time for Ketorolac?
45 to 60 minutes
This timing is advantageous for pain management during emergence.
What are some contraindications for using Ketorolac?
- Severe renal impairment
- Active bleeding
- History of peptic ulcer disease
- Allergies to NSAIDs
These factors must be carefully considered before administration.
What are the effects of ibuprofen as a non-specific NSAID?
- Anti-inflammatory
- Analgesic
- Antipyretic
It inhibits both COX-1 and COX-2 pathways.
What are the main properties of ibuprofen?
Anti-inflammatory, analgesic, antipyretic
Ibuprofen inhibits both COX-1 and COX-2 via the cyclooxygenase pathway.
What is an absolute contraindication for ibuprofen?
Allergy to NSAIDs
Common in patients with systemic lupus erythematosus (SLE) who may be allergic to aspirin.
What is the maximum daily dose of ibuprofen?
3200 mg
This is the maximum limit within a 24-hour period.
What is the typical dosing schedule for ibuprofen IV?
200 to 800 mg IV over 30 minutes every six hours PRN
PRN stands for ‘as needed’.
When should ibuprofen be administered preoperatively?
Start in pre-op for analgesic effects
Especially important for pain management during recovery.
What is the peak effect time for ibuprofen?
1 to 2 hours
This is when the drug reaches its maximum effect.
What is the mechanism of action for lidocaine?
Sodium channel blocker
Lidocaine is used as both a local anesthetic and an antiarrhythmic agent.
What are the available concentrations of lidocaine for peripheral nerve blocks?
1% and 2%
1% lidocaine contains 10 mg/ml, while 2% contains 20 mg/ml.
What is the typical dosing for lidocaine IV?
1 to 2 mg/kg IV bolus over 2 to 4 minutes, then 1 to 2 mg/kg/hour drip
This is important to prevent lidocaine toxicity.
What are the side effects of lidocaine toxicity?
Circumoral numbness, tinnitus, seizures, cardiac depression
Monitoring is crucial to prevent severe adverse effects.
What role does magnesium play in pain management?
NMDA receptor antagonist, potentiates opioids
Magnesium also regulates calcium access into cells.
What is the contraindication for magnesium administration?
Myasthenia gravis and renal failure
Magnesium can cause muscle weakness, which is risky for these patients.
What is the typical dosing for magnesium IV?
15 mg/kg IV bolus, then 8 mg/kg/hour drip
Adjustments may be needed based on patient response.
What is the mechanism of action for ondansetron (Zofran)?
5-HT3 receptor antagonist
It is primarily used for nausea and vomiting but does not have direct analgesic properties.
What are common side effects of ondansetron?
Headaches, constipation, QT prolongation
QT prolongation is more likely with rapid administration.
What is the typical dosing for ondansetron IV?
4 to 8 mg IV
Pediatric dosing is 0.1 mg/kg IV.
What is the role of dexamethasone (Decadron) in nausea management?
Anti-inflammatory and enhances the effectiveness of Zofran
It stabilizes cellular membranes and inhibits phospholipids and cytokines.
What is the dosing for dexamethasone?
4 mg IV
Often given as part of multimodal protocols for nausea prevention.
What is the significance of using dexamethasone with peripheral nerve blocks?
Extends the duration of local anesthetics
Studies show it enhances the effectiveness of nerve blocks.
What is the effect of Decadron when used as an adjunct for a peripheral nerve block?
It extends the life of the block, providing pain relief for 24 to 48 hours.
Decadron is often used to enhance the efficacy of local anesthetics in peripheral nerve blocks.
How does the administration of Decadron differ when given IV versus mixed with local anesthetic?
Both methods appear to work the same, but the IV method may prolong the block effect without mixing it directly with the anesthetic.
Literature supports both administration methods.
When is the ideal timing for administering Decadron prior to surgery?
It is usually recommended to give it prior to incision, but it can be administered in pre-op to ensure efficacy.
The onset can be delayed by two hours.
What are the potential adverse effects of Decadron in diabetic patients?
There are no adverse effects from a single dose with diabetics, according to meta-analyses.
Studies show stability in blood sugar levels with single doses.
What is the primary benefit of using Decadron in post-anesthesia care?
It helps in controlling nausea and vomiting and improves pain management.
Decadron is effective in multimodal analgesia.
What potential side effect should be monitored when administering Decadron?
Perineal burning or itching, especially in female patients.
Slow administration is advised to minimize this effect.
What is the impact of enhanced recovery after surgery (ERAS) protocols on hospital stay and complications?
They can reduce hospital stay and complications by 30 to 50%.
ERAS focuses on minimizing opioid use and enhancing recovery.
What are the three pillars of ERAS protocols mentioned?
- Avoiding short-acting IV sedatives
- Using alternatives to opiates (e.g., acetaminophen, NSAIDs)
- Administering dexamethasone and gabapentin
These components aim to enhance recovery and reduce opioid requirements.
What is methadone’s current status in ERAS protocols?
There are mixed studies on its efficacy, and it is not widely used yet.
Its potential legalization in various states may change its status.
What is the elimination half-time of dexmedetomidine compared to clonidine?
Dexmedetomidine has a half-time of 2 to 3 hours, while clonidine is 6 to 10 hours.
This makes dexmedetomidine potentially safer due to its shorter action.
What is a key consideration when using dexmedetomidine for sedation?
It can depress ventilation, necessitating a secured airway during use.
Monitoring is crucial, especially at higher doses.
What is the recommended bolus dose of dexmedetomidine?
0.5 to 1 mcg/kg over 10 minutes.
This dosing is critical in avoiding adverse effects.
What should be considered when asking patients about their smoking habits?
Inquire specifically about cannabis use in addition to traditional tobacco products.
Cannabis use is increasingly common and should be addressed in pre-op assessments.
What does the Society for Opioid Free Anesthesia focus on?
They promote opioid-free anesthesia techniques.
Their presentations often cover alternative pain management strategies.
How much lidocaine is administered to a 60 kg patient in the example given?
60 mg initially, followed by a subsequent infusion calculated based on the patient’s weight and time.
The total dosage calculation is essential for patient safety.
What is the significance of dexmedetomidine in total IV anesthesia?
It decreases the perioperative requirements for inhaled anesthetics by 90%.
This highlights its effectiveness in reducing overall anesthetic use.
What is the recommended dosing for dexmedetomidine when used in epidural anesthesia?
2 mcg/kg for epidural compared to 3 or 5 mcg for intrathecal administration.
This difference accounts for the need for diffusion across the dura.
