GA: Emergence - Exam 2 Flashcards
Ways to emerge more smoothly(time wise):
-SA agents for short cases
-avoid excessive premed
-prepare to switch techniques/ agents at end of long case
-time meds and doses
GA components that affect emergence timeframe
-FGF (high=fast, low=slow) ***
-Ventilation (hyper=fast, hypo=slow)
-Concentration gradient (BG and OG coefficients)
-Eliminating rebreathing (high FGF)
-pts BMI (high, may last longer)
-duration of GA (IA can take days to wear off -lipid soluble, maybe sent to ICU on vent)
-type of surg (neck and airway surg, do NOT want pt coughing on emergence, maybe emerge DEEP)
Until FiAA reaches _ on gas analyzer you are still giving IA to pt
0
You have washed your pt’s IA out with high MV and high FGF of O2, why aren’t they breathing?
Could have also washed out CO2 to a point where hypercarbic reflexes are diminished
-back off on higher flows, slow their RR maybe, shorter exp time may help
How will I know when my TIVA pt should be waking up?
know your beta half lives!
TOF adductor pollicis or orbicularis oculi
-twitches to receptor block %
-time to recovery
1= 90% blocked - 30min
2= 80% blocked - 3-15min
3= 75% blocked - 3-15min (still 30 min for pancuronium)
4= 0-70% blocked -<5min
Onset of paralysis happens in this order:
-eye muscles, extremities, trunk, diaphragm
-will recover in opposite order so monitor facial n on induction and ulnar n for recovery
T/F You should give anticholinergics to reverse NMBD if you don’t have any twitches.
no, try PTC if 0/4 on TOF
-1 twitch = reversal in 30 min
-2-3 twitches = recovery in 4-15 min
-4/4 twitches = total recovery in 5 min
If pt is 75% blocked per TOF they can have:
-5 sec head lift
-15-20mL/kg VC
–25cmH2O NIF
-effective cough
TOF outputs should be _mA
30
For monitoring recovery from NMBD which is better, quant or qual?
quantitative data
When can I reverse my NMBD?
Must have 1 TOF twitch
-also consider timing+conc of last dose + if spont resp effort is seen
If I don’t have any TOF twitches but use PTC and have 7-8 twitches will I have 1 TOF twitch soon?
Yes, like <10 min
-more twitches, sooner until TOF will give a twitch
Which NMBD wears off the slowest according to PTC?
PANCuronium
-by 6-10 twitches most other NMBD have given 1 TOF twitch but PANCuronium will usually give 1TOF by 11 twitches
How do anti(acetyl?)cholinesterase drugs work for reversal?
increase amount of ACh at receptors by preventing their breakdown EVERYWHERE
-hence following MUSCARINIC effect of bradycardia which it treated with antimuscarinics :)
T/F Neostigmine is an anticholinergic
HELL NAW, its an AChE inhibitor!!! -increases ACh
AChE Inhibitors
-Edrophonium dose, onset, DOA
0.5-1mg/kg
onset: 30-60 sec, peak:1-5 min
DOA: 5-20 min
AChE Inhibitors
-Edrophonium tips
-only administer if pt has 4 visible twitches
-goes better w/ Atropine bc similar onset
AChE Inhibitors
-Neostigmine dose, max, onset/peak, DOA
0.04-0.08 mg/kg, MAX 5mg total
onset: 1-5 min peak: 7-14 min
DOA: 30-60 min
AChE Inhibitors
-Neostigmine tips
-give with Glyco, similar onset
-give 0.2:1 glyco and neo
AChE Inhibitors
-Pyridostigmine dose
0.1-0.25mg/kg
-not used often
AChE Inhibitors increase ACh everywhere but we only want to stimulate the _ receptors and avoid _ action so we give anticholinergics with them
nicotinic (desired)
muscarinic (undesired effects)
Anticholinergic/ Antimuscarinics
Atropine dose + tip
7-15mcg/kg
-lipophilic, can cross BBB, placenta, and cause CNS s/e like hallucinations/sedation
Anticholinergic/Antimuscarinics
Glycopyrolate dose + tip
0.01-0.02mg/kg
Glyco gecko is tiny!
-better antisialagogue (antisaliva drug); ionized and won’t cross BBB
Suggamadex
-class + MOA
GAMMA CYCLODEXTRIN
-encapsulates amino steroidal MR and deactivates them (roc+vec)
Suggamadex
-A/E
Hypersensitivity
-rash,flushing,anaphylaxis
-happens IMMEDIATELY
-higher dose, higher risk
Arrhythmias
-BRADY, asystole
-emergency drugs! (ASO4 AKA Atropine(sulfate) !!!!)
Suggamadex
-dose
2,4,16
TOF dependent!
-No TOF twitches but PTC of 1-2= 4mg/kg (reverses in 3 min)
-TOF 2/4= 2mg/kg (reverses in 1-1.5min)
-After RSI Roc dose= 16mg/kg (reverses in 3 min)
Suggamadex
-tips
-do NOT need a anticholinergic
-can inhibit PO contraceptives!
Reversal speed depends on:
-depth of block
-type of AChE (edrophonium>Neo>Pyridostig)
-dose of AChE (too much ACh can cause DEPOLARIZING blockade)
-spont reversal and metabolism of NMBD
-conc of IA
Over reversal can cause a _ _ from excessive _ and _ effects
cholinergic crisis
nicotinic
muscarinic
Cholinergic Crisis
-s/s
-wet (secretions)
-bronchospasm
-resp paralysis (musc)
-BRADY (musc)
-diarrhea
-miosis (musc)
-muscle weakness / fasciculations (nicotinic)
Cholinergic Crisis
-diff dx from Myasthenic Crisis
similar s/s ; give EDROPHONIUM 2mg IV
-if Myasthenic crisis it should help, if it WORSENS, it’s cholinergic***
Cholinergic Crisis
-tx
-stop AChE inhibitor therapy
-make sure isnt Myasthenic
-give atropine
-resp support PRN
Signs of full reversal
-objective
-TOF = 4 twitches = 0-70% blocked
-TOFR > 0.7-0.9 is KEY*
-sustained tetanus 50-100Hz >5sec without fade = 0-70% blocked
-NIF >40cmH2O
-VC >20mL/kg
-Vt >5mL/kg
Signs of full reversal
-subjective
-5s head lift
-tongue purposeful movement
-strong hand grip
-spont breathing with good Vt (not super reliabe)
-RR smooth
-eye open on command
-+cough, swallow, bite, arm lift
-LOC ok
Why would spont breathing and good Vt NOT be a clear sign of full reversal?
Bc diaphragm movement returns before tongue or airway reflexes! (ability to protect airway)
How to pvn my pt from waking up in pain?
Time narc carefully
-LA narcs in maintenance phase
-SA narcs titrated to RR
-use doses ok for AWAKE pt
Multimodal anesthesia/ pain control
Regional options
How to pvn my pt from vomiting?
-impact of vomiting
Common cause of unplanned admission
-aspiration
-altered lytes
-dehydration
-BLEEDING from wound
-wound DEHISCENCE (from retching)
How to pvn my pt from vomiting?
- pt risk factors
Pt
-intraabdominal disease
-full stomach
-NONsmoker
-young, female
-HX OF PONV
