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xPharm Exam 2 > Generalized Anesthesia > Flashcards

Generalized Anesthesia Flashcards

1
Q

Inhaled Anesthetics (6)

A
  • Isoflurane
  • Desflurane
  • Sevoflurane
  • Halothane
  • Nitrous Oxide

NEW: Halogenation increases potency and is non-flammable

OLD NOTES: All but Nitrous Oxide are halogenated, which adds stability, increases solubility and potency [TQ]

(DISH N)

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2
Q

IV Anesthetics (6)

A
  • Benzodiazepines (Midazolam)
  • Opioids
  • Ketamine
  • Propofol
  • Etomidate
  • Dexmedetomidine

(BOP-KED)

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3
Q

Sedatives (5)

A
  • Benzodiazepines (Anxiolytics and Hypnotics)
  • Propofol
  • Dexmedetomidine
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4
Q

Isoflurane (6)

A
  • Flourine + Chlorine
  • Lowest MAC at 1.15%
    • (most potent, good)
  • Highest Blood:Gas Partition Coefficient
    • (lower affinity of blood or anesthetic, bad)
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5
Q

Desflurane

A
  • Flourine
  • Highest halogenated MAC (6.3%)
  • Lowest Blood:Gas Partition Coefficient
    • Good!
    • Lower Blood Solubility
    • More rapid anesthetic effect and recovery
  • Not used for induction (high pungency, high RI)
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6
Q

Sevoflurane

A
  • Flourine
  • Between Desflurane and Isoflurane for both MAC and Blood:Gas Partition Coefficient
  • Causes seizures and agitation
  • Used for induction, low pungency and low RI
  • OLD: Useful in patients with myocardial ischemia [TQ]
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7
Q

Nitrous Oxide

A
  • Produces anesthesia without decreasing BP or CO
  • Can cause myocardial depression, offset by gas-associated sympathetic stimulation
  • Amnestic and analgesic properties
  • Decreases requirements of inhaled and IV anesthetics
  • 25-40%: CNS depression (safely used clinically)
  • 25%: produces maximum analgesic effects
  • Unconscious at inspired levels of 60-80%
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8
Q

Benzodiazepines: as IV anesthetics

A
  • Midazolam
  • Bind close to GABAa receptor and trigger opening of Cl channel, Cl ion influx (hyperpolarization) inhibits AP formation
  • Preferred agent for balanced anesthesia
  • Active metabolie – accumulation (caution with multiple doses)
  • Uses: sedation, hypnotic (high doses), anticonvulsant, muscle relaxant, anxiolytic, anterograde amnesia [TQ], preserves hemodynamic stability
  • Antidote: Flumazenil
  • ADRs: respiratory depression
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9
Q

Midazolam

A
  • Preferred agent for balanced anesthesia
  • Synergistic other agents (propofol), opioids:
    • decreased dose requirements
    • potentiation with opioids
    • respiratory depression is enhanced though
  • Rapid onset (30-60 sec), peak 60 min
  • ADRs: dose-dependent respiratory depression, active metabolite accumulation
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10
Q

Flumazenil (4)

A
  • Antidote for Benzo overdose
  • Binds to same receptor without enhancing GABA binding
  • Onset (1-2 min), peak (10 min), dose-dependent DOA
  • High safety margin
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11
Q

Opioids

A
  • Interact at Mu receptors in CNS and GI tract
  • Uses: analgesia and sedation (no amnesia)
  • ADRs: respiratory depression, post-operative nausea/vomiting, bradycardia, hypotension
  • Risk factors: co-administration with sedatives, old people, high doses
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12
Q

Remifentanil

A
  • First Mu-opioid receptor agonist
  • No histamine release
  • Rapid onset and recovery
  • Uses: ED, ICU, procedures in SDS or endoscopy, combo therapy for induction
  • Disadvantages: sudden onset of pain or withdrawal
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13
Q

Naloxone

A
  • Competitive opioid antagonist, strong mu affinity
  • No analgesic effects
  • Narcotic reversal in 1-3 min (IV)
  • Ventilation can be restored without losing pain benefit of narcotic
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14
Q

Ketamine

A
  • PCP analog, slow onset
  • Enhanced response to glutamate at NMDA receptor
  • Interacts with CNS opiate receptors for pain relief
  • Low dose: analgesia/anxiolysis for debridement/dressing changes
  • Moderate dose: analgesia/anxiolysis plus sedation and amnesia
  • High dose: used in prolonged surgical procedures (impairs airway reflexes)
  • ADRs: dissociative anesthesia [TQ] (patient appears awake but unconscious and doesn’t feel pain)
    • give with benzos to alleviate side effects
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15
Q

Propofol: as IV anesthetic

A
  • GABA mechanism
  • Rapid onset (90 seconds), DOA (5-10 min), very apid recovery, hepatic elimination, easily titrated
  • High lipid concentration, careful for bacterial growth
  • Uses: long or short procedures, good for induction in ambulatory procedures, sedative hypnotic
  • No analgesia and no amnesia
  • ADRs: nausea/vomiting, residual drowsiness, pain on injection (give with lido), apnea, hypotension, respiratory depression, allergic reactions (egg whites)
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16
Q

Etomidate (6)

A
  • Depresses RAS and mimics effects of GABA
  • Onset (30-60 seconds), DOA (3-5 min)
  • Uses: IV induction, procedural sedation
  • Advantage: hemodynamic stability
  • ADRs: adrenal suppression [TQ]
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17
Q

Dexmedetomidine: as IV anesthetic

A
  • a2-Receptor agonist (like clonidine)
  • Don’t use alone, useful for decreasing amount of opioid required and therefore decreasing side effects (sparing effect)
  • Hepatic metabolism, T1/2: 2 hours
  • Ability to awaken patients more easily
  • Uses: anesthetic, sedative, minimal analgesia
18
Q

Benzodiazepines: as sedatives

A
  • Not the preferred method (propofol/dex are)
  • Cons:
    • associated with worse clinical outcome
    • slow onset, metabolism and excretion
  • Pros:
    • alcohol/sedative withdrawal
    • intractable seizures
    • sedation when paralyzed
    • calming effect of intermittent dosing
19
Q

Propofol: as a sedative

A
  • Rapid onset/offset, shorter ICU length of stay
  • Titratable
  • Uses: deep sedation (ventilator, deep hypothermia),
    • frequent neurologic checks
    • status epilepticus,
    • open wounds
  • Add analgesia
  • Watch BP and triglycerides
20
Q

Dexmedetomidine: as a sedative

A
  • Very expensive, limited FDA approval
  • Reduces narcotics requirements
  • Light sedation (don’t use with paralytics)
  • Can use in extubated patients (doesn’t depress respiratory drive)
  • Causes hemodynamic changes and shivering
21
Q

Which has the best analgesic effects?

  • Opioids
  • Benzos
  • Propofol
  • Haloperidol
A
  • OPIOIDS: ****
  • Propofol: *
  • Haloperidol: *
22
Q

Which has the best anxiolytic effects?

  • Opioids
  • Benzos
  • Propofol
  • Haloperidol
A
  • BENZOS: ****
  • HALOPERIDOL: ****
  • Propofol: ***
  • Opioids: **
23
Q

Which causes respiratory depression?

  • Opioids
  • Benzos
  • Propofol
  • Haloperidol
A

-OPIOIDS: ****

24
Q

Which has the best amnesia effects?

  • Opioids
  • Benzos
  • Propofol
  • Haloperidol
A

-Benzos: ** -Propofol: **

25
Q

4 Stages of Anesthesia

A
  1. Induction
  2. Excitement
  3. Surgical Anesthesia
  4. Overdose
26
Q

3 Drugs used for IV induction

A
  1. Propofol
  2. Etomidate
  3. Ketamine

(PEK you with a needle)

27
Q

7 Perianesthetic Agents

A
  1. Antihypertensives: for low BP
  2. Beta agonists: treat asthma/laryngospasm
  3. Anticholinergics: prevent bradycardia and excess fluid secretion
  4. Antihistamines: prevent allergic reactions and reduce gastric acidity
  5. Antiemetics: treat nausea/vomiting
  6. Benzodiazepines: amnesia, sedation
  7. Opioids: analgesia
28
Q

TIVA (6)

A
  • Total IV Anesthesia
  • Propofol
  • Target controlled infusions
  • Less post-operative nausea and vomiting
  • More costly, short cases
  • Indications: history of malignant hyperthermia, needle phobia
29
Q

Potency of Inhaled Anesthetic MAC (8)

A
  • Minimum Alveolar concentration
  • Reflects the dosage required to produce desired anesthesia
  • Alveolar concentration of inhaled agent at 1 atmosphere of pressure that prevents movement in 50% of patients
    • Nitrous Oxide: 105% MAC
    • Desflurane: 6.3% MAC
    • Sevoflurane: 2% MAC
    • Isoflurane: 1.15% MAC
  • MAC decreases with age and pregnancy [TQ]
  • High MAC = Decreased Potency [TQ]
30
Q

Partial Pressure (4)

A
  • The pressure exerted by that gas alone
  • Normal gas transport - passive (driven by concentration gradient)
  • Gases in body may bind (oxygen to hemoglobin) or transform (CO2 to HCO3)
  • Controlling partial pressure manages anesthetic gas concentration in brain
31
Q

4 stages of equilibrium during anesthesia

A
  1. Anesthesia machine
  2. Alveolar spaces
  3. Arterial blood
  4. Brain tissues
32
Q

Blood:Gas Partition Coefficient (4)

A
  • Ratio of [anesthetic in blood phase] to [anesthetic in gas phase]
  • Partition coefficient: 0.5 if arterial concentration is 3% or lung concentration is 6%
  • Low= low affinity of blood for anesthetic (this is good, more precise control and rapid recovery)
  • Desflurane has lowest Blood:Gas Partition Coefficient (on chart) at just over 0.4
33
Q

Malignant Hyperthermia

A
  • Muscle rigidity, rhabdomyolysis, fever, tachycardia, acidosis
  • Family history
  • When confirmed: discontinue inhalation agent, hyperventilate, use non-triggering agents to finish, intubate, dantrolene [TQ]
34
Q

5 Causes of Agitation

A
  1. Physiologic: pain, constipation, nausea, thirst
  2. Chemical: hypoglycemia, electrolyte imbalance
  3. Pharm: steroids, sedatives, anticholinergics
  4. Emotional: anxiety, confinement, restraints
  5. Environment: noise, altered circadian rhythms, no sleep
35
Q

PAD Guidelines (7)

A
  • Consensus document
    • P: Pain (pain scores)
    • A: Agitation/Sedation (RASS)
    • D: Delirium (CAM-ICU)
  • Representative of best practice
  • Base decisions on: patient condition, local practice norms and resource availability
  • First address: withdrawal, psychiatric drug resumption
36
Q

Analgo-Sedation (5)

A
  • Analgesia then sedation
  • Short acting IV opioid (alleviate need for sedative, control pain, improve outcomes, earlier mobilization, reduce delirium, facilitate ICU discharge)
  • Practice routine evaluation with valid/reliable scales
  • Pain indicators should evaluate pain at rest and before potentially painful procedures
  • Titrate
37
Q

Agitation and Sedation (2)

A
  • Prior to sedation: provide analgesia, reorient to surroundings, maintain normal sleep-wake cycle
  • Options: benzos, propofol, dexmedetomidine
38
Q

Titrate/Balance Sedation in ICU (2)

A
  • Reduce over/under sedation
  • Advantages: optimize comfort/safety, minimize time in ICU, Communicate with other caregivers, titrate to pre-specified goals/ranges
39
Q

RASS (4)

A
  • Richmond Agitation Sedation Scale
  • 0: alert/calm
  • +4: combative, violent
  • -5: unarousable, no response to voice or physical stimulation
40
Q

What level is surgical anesthia?

A

3

41
Q

T/F: you want to administer pre-anesthetics before surgery to stimulate patient

A

False

xPharm Exam 2 (8 decks)

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