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Anesthesia Pharm > Exam 3 part V > Flashcards

Exam 3 part V Flashcards

1
Q

which concentration of epi would have a higher plasma concentration @ 1mL (thus increased risk of toxicity) - 1% or 2%

A

2% ; 2% = 20 mg/ml which is a higher DOSE than 1%. plasma concentration of LA is directly proportional to the dose

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2
Q

plasma concentration of lido is directly proportional to the ________________

A

dose

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3
Q

all LA anesthetics cause vasodilation –> increased absorption, decreased DOA, and increased risk of toxicity EXCEPT _____________, __________, _____________

A

cocaine (inhibits reuptake of NE) lidocaine ropivicaine

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4
Q

what is the rapid phase of the two compartment model (for LA)

A

highly perfused tissues (VRG) reach equilibrium quickly

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5
Q

what is the slow phase of the two compartment model (for LA)

A

equilibrium of lesser perfused tissues happens slower

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6
Q

which tissue group recieves the highest concentration of LA from redistribution

A

muscle group

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7
Q

order of distribution of LA throughout the body

A
  1. VRG 2. muscle group 3. fat group 4. vessel poor group
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8
Q

saturated, inhibited, or atypical p-AchE can _______________ the 1/2 life of __________ LA

A

prolong; ester

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9
Q

all amide LA are metabolized by the hepatic biotransformation via CYP450 except __________________, which is metabolized via _____________________

A

articaine; plasma cholinesterase

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10
Q

T/F: poorly functioning P-AchE effects DOA of ester LA

A

false; the absorption away from the site of action remains unchanged

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11
Q

Amides should be avoided in patients with ____________________

A

renal failure

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12
Q

if pt has hepatic dysfunction you should _______________ single dose and ____________ infusions of amide LA

A

make no adjustment; decrease by 10-50%

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13
Q

during pregnancy, women will have increased ______________ & __________ of the LA with spinals and epidurals

A

spread; depth

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14
Q

why do pregnant women have increased spread and depth of LA with spinals and epidurals

A
  1. decreased thoracolumbar CSF 2. increased susceptibility to LA d/t increased progesterone 3. gravid uterus = dilated epidural veins = narrowed SA and epidural space
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15
Q

modification to dose of LA in spinals and epidurals for pregnant women

A

you decrease dose

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16
Q

T/F: epi markers will prolong the DOA to the same extent with all LA

A

FALSE

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17
Q

purpose of epi additives to LA

A
  1. used to detect intravacular injection with PNB and epidurals 2. prolongs the intensity of the block 3. increases safety, quality, rate of onset, and reduced blood loss
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18
Q

epi markers in LA will have much more pronounced effects with ____________acting LA

A

short

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19
Q

how do epi markers prolong the intensity of the LA

A

local vasoconstriction which: 1. decreases rate of vascular absorption 2. decreases risk of toxicity 3. increases the LA available at the site

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20
Q

what is the typical concentration of epi with LA

A

1:200,000 (5 mcg/mL)

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21
Q

when testing an epidural catheter you are going to place _________ cc of LA + epi, and if you are in the right place, ______________ will happen

A

3; nothing (no raise in HR, BP, or anesthesia)

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22
Q

effect of vasoconstrictive additive on the LA is influenced by:

A
  1. drug (LA and vasoconstrictor) 2. dose of each 3. concentration of each 4. site of injection
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23
Q

what vasopressor drugs can be used as additives to LA

A
  1. epi (superior) 2. phenylephrine 3. norepinephrine
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24
Q

which vasoconstricting additive is the best for the nerve stimulator technique with peripheral blocks

A

epi

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25
Q

alpha2 adrenergic agonist additives to LA are most effective on ______________ & ____________ fibers

A

C (sensory); A-delta (motor)

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26
Q

MOA of adding alpha 2 agonist to LA

A
  1. effect spinal and supraspinal receptors 2. interrput the nerves ability to achieve resting membrane potential from the inactive state
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27
Q

alpha-2 agonists are added to LA for what type of blocks

A
  1. caudal (peds) 2. neuraxial 3. PNB
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28
Q

s/e of adding clonidine to LA block

A
  1. hypotension 2. bradycardia 3. sedation
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29
Q

______________ mcg of clonidine added to LA will increase analgesic effect by about _______________ minutes

A

100; 100

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30
Q

“updosing an epidural” means that you are adding _________________ to the LA

A

sodium bicarbonate

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31
Q

sodium bicarb is widely used as an additive to LA in ________________ anesthesia

A

epidural

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32
Q

effects of adding sodium bicarb to LA in epidural

A
  1. increases the pH of the solution –> increased non-ionized form of LA 2. with injection more LA crosses the membrane –> increased speed of onset 3. also decreases pain and stinging
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33
Q

if adding sodium bicarb to LA you should beware of NaHCO3 ability to __________________

A

precipitate

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34
Q

effect of adding hyaluronidase to LA

A

increases the spread of LA via facilitating diffusion into the nerve

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35
Q

MOA of hyaluronidase

A

enzyme that hydrolysis hyaluronic acid (which inhibits the spread of substances through tissues)

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36
Q

hyaluronidase as an additive to LA is commonly seen with _______________ procedures

A

opthalamic

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37
Q

potential adverse effects of hyaluronidase into LA

A
  1. allergic response 2. shorten DOA 3. increased risk of toxicity
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38
Q

what types of blocks can ketamine be added to

A
  1. spinals (intrathecal) 2. epidural 3. PNB
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39
Q

what is the effect of adding ketamine to LA for an intrathecal (spinal) injection

A
  1. shortens onset of LA analgesia 2. shortens DOA of analgesia
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40
Q

what is the effect of adding ketamine to LA for epidural

A

effect is unclear

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41
Q

what is the effect of adding ketamine to LA for PNB

A

prolongs post-op analgesia

42
Q

what concentration of ketamine would you expect to add to LA for regional anesthesia?

A

50 or 100 mg/mL

43
Q

opioids as additive or single agent can only be used for _________________ blocks

A

neuraxial

44
Q

what is the other name for morphine that is specifically used in neuraxial anesthsia

A

duramorph - preservative free morphine

45
Q

which opioids can be added or used a sole agent for spinal anesthesia

A
  1. intrathecal morphine 2. intrathecal fentanyl 3. intrathecal sufentanil
46
Q

what is the dose of morphine if used as additive or sole agent in spinal or epidural?

A

0.1-0.2 mg

47
Q

intrathecal morphine (spinal) can provide analgesia for ____________ hours post C-section

A

20

48
Q

s/e of intrathecal morphine (duramorph)

A

pruritus commonly atarax given with it because itching is SO bad

49
Q

dose of intrathecal fentanyl

A

10-25 mcg

50
Q

effects of intrathecal fentanyl on your block

A
  1. improves spread 2. prolongs block 3. dose dependent effects
51
Q

dose of intrathecal sufentanil

A

5 mcg

52
Q

5 mcg of intrathecal sufentanil is similar to a _________ mg intrathecal dose of morphine

A

0.2

53
Q

benefit of intrathecal sufentanil over morphine / fentantyl?

A

shorter DOA with decreased pruritus

54
Q

epidural morphine is a _________________ shot that is effective for postop analgesia in ________________ & _______________ procedures

A

single; ortho; OB

55
Q

___________________ with epidural morphine can last longer than analgesic effect, monitor closely and be sure to report that you used it to recovery staff

A

respiratory depression

56
Q

dose of epidural fentanyl

A

2 - 10 mcg /mL

57
Q

dose of epidural sufentanil

A

0.75- 1.0 mcg/mL

58
Q

T/F: IV effects of sufenta = epidural effects of sufenta

A

TRUE

59
Q

dose of hydromorphone in epidural

A

20 mcg/mL

60
Q

what opioids can be added or used as sole agent in epidural

A
  1. morphine (single shot) 2. fentanyl 3. sufentanil 4. hydromorphone
61
Q

respiratory depression is a common s/e with opioids in neuraxial anesthesia, but onset varies. place in order from earliest onset to latest onset respiratory depression with epidural opioids

A
  1. sufentanil (earliest onset d/t most lipophillic) 2. fentanyl 3. hydromorphone 4. morphine (latest onset)
62
Q

dose of ketamine for intrathecal block

A

5-25 mg

63
Q

dose of clonidine for neuraxial or PNB block

A

max = 1 mg/kg of ideal body weight

64
Q

decadron is commonly added to ________________ blocks

A

peripheral

65
Q

dose of decadron additive to PNB

A

2-4 mg

66
Q

dose of precedex in spinal

A

10 mcg

67
Q

dose of precedex in epidural

A

0.5 mcg/kg

68
Q

dose of precedex in peripheral nerve block

A

0.5-1 mcg/kg

69
Q

ion trapping is an effect of LA that can happen with what situations ?

A
  1. respiratory depression, hypoxia, acidosis 2. LA injection into infected tissues 3. storage of LA in acidic solutions 4. LA accumulation into fetal circulation
70
Q

why is there ion trapping of LA with respiratory depression, hypoxia, and acidosis

A
  1. increased ionization of LA within CNS 2. decreases ability of LA to cross BBB out of the brain 3. potential to prolong and enhance CNS toxicity of LA
71
Q

effect of injecting LA into infected tissues

A

infected tissues are acidotic and have no lipid solubility –> LA ionizing and being ineffective bc it cannot absorb

72
Q

why do you have ion trapping of LA in the fetal circulation

A

fetal pH is lower than maternal pH –> LA enters fetal blood ionizes and is trapped in fetal circulation potential for high fetal levels of LA

73
Q

if LA was stored in the non-ionized form what would happen

A
  1. can photodegradgate 2. forms aldehydes –> aldehyde toxicity
74
Q

which agent is MOST likely to cause LAST

A

bupiv

75
Q

causes of LAST

A
  1. inadvertent IV injection or absorption of large amounts of drugs 2. occasionally d/t continuous infusions 2/2 accumulation of drug/metabolites over many days 3. high systemic blood levels
76
Q

single injection LA will have onset of LAST within ____________ minutes; continuous infusions it will take __________________ before see sx

A

5 (but as fast as 30-60 s); hours or days

77
Q

LAST occured most commonly in which type of block?

A

single shot epidurals

78
Q

LAST prevention

A
  1. test doses 2. incremental dosing 3. using pharmacologic biomarkers (epi) 4. restricted use of 0.75% bupiv in OB 5. use the lowest dose possible
79
Q

sx of LAST

A
  1. lightheadedness 2. tinnitus 3. circumoral and tongue numbness 4. metallic taste 5. visual disturbances 6. muscle twitching 7. unconsciousness/convulsions 8. coma 9. respiratory arrest 10. CVS depression
80
Q

which agents cause CV depression the most (with LAST)

A
  1. bupiv ** (MOST) 2. tetracaine 3. etidocaine
81
Q

systemic blood levels of LA vary with?

A
  1. area of blockade 2. technique 3. specific drug used
82
Q

if performing regional anesthesia you should always be prepared to manage what complication?

A

LAST

83
Q

tx of LAST

A
  1. airway management - 100% FiO2 2. seizure suppression - BZ 3. BLS/ACLS 4. infuse 20% lipid emulsion 5. call cardiopulmonary bypass team & make arrangements for the possibility it is needed 6. keep epi doses < 1 mg/kg
84
Q

if you suspect LAST and your patient goes into cardiac arrest, what drugs should be avoided

A
  1. vasopressin 2. CCB 3. BB 4. LA 5. propofol (if pt is grossly HD unstable)
85
Q

if you perform a regional block, you should consider LAST in any pt with:

A
  1. altered mental status 2. neurologic sx 3. CV instability
86
Q

T/F: propofol is a substitute for lipid emulsion therapy in tx’ing LAST

A

FALSE

87
Q

effects of 20% lipid emulsion with LAST tx

A
  1. lipid sink - captures LA in blood 2. metabolic effect - increases fatty acid uptake 3. membrane effect - interference with LA binding to VG Na channel 4. cytoprotection - activation of the Akt cascade 5. ionotropic effect - promotes Ca entry via VG Ca channels 6. pharmacokinetic effect - accelerated shunting
88
Q

recommended dosing of 20% lipid emulsion in Tx of LAST

A

DOSING ON LEAN BODY MASS 1. initiate IV bolus of 1.5 cc/kg 2. continue infusion at 0.25 cc/kg/min x 10 min after return of cardiac fx 3. if CV instability continues, consider repeating bolus and increasing infusion to 0.5 cc/kg/min 4. max = 10 cc/kg over 30 min for initial dosing

89
Q

you can redose the 20% lipid emulsion bolus _____________x

A

2-Jan

90
Q

T/F: 20% lipid emulsion therapy can be used to treat LAST in pregnant patients

A

TRUE

91
Q

which LA cause methemoglobinemia

A
  1. benzocaine 2. prilocaine
92
Q

tx of methemoglobinemia

A

methylene blue 1-2 mg/kg IV over 30 min

93
Q

benzocaine and prilocaine are c/i under the age of __________ 2/2 ability to cause ___________________

A

2; methemoglobinemia

94
Q

what is methemoglobinemia

A

when Fe2+ (ferrous form of hgb) is oxidized to form Fe3+ (ferric form of hgb)

95
Q

high concentrations of metHb in the blood causes ________________ & ____________

A
  1. tissue hypoxia 2/2 reduced capacity to carry O2 2. left shift of the oxyhgb curve
96
Q

s/sx of methemoglobinemia

A
  1. cyanosis 2. decreased SaO2 despite O2 tx 3. chocolate colored blood 4. tachypnea/tachycardia 5. confusion 6. HA 7. dizziness 8. coma 9. death
97
Q

cauda equina syndrome

A

irritation of the sacral spinal cord

98
Q

which LA was responsible for cauda equina syndrome due to inadvertent intrathecal injection

A

chloroprocaine

99
Q

sx of cauda equina syndrome

A
  1. acute loss of function to the lumbar plexus 2. saddle anesthesia (S3-S5 dermatome) –> pins and needles in perineum, genitals, anus, and lower extremities 3. bowel and bladder dysfunction 4. could be permanent
100
Q

cauda equina syndrome 2/2 LA injection disappeared when they started using ____________________

A

preservative free solutions

Anesthesia Pharm (18 decks)

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