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Oral Boards > Hypnotics > Flashcards

Hypnotics Flashcards

1
Q

Propofol Class

A

Hypnotic

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2
Q

Propofol Indications

A

induction, maintenance of anesthesia, MAC, anticonvulsant, antiemetic

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3
Q

Propofol Mechanism of Action

A

mimics GABA @receptor, directly activates cl- channels –> hyper-polarizes the postsynaptic membrane

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4
Q

Propofol Dosing

A

Induction of GA: 1-2.5 mg/kg
Maintenance of GA: 25-300 mcg/kg/min IV
Sedation: 25-100 mcg/kg/min
Antiemetic 10-20 mg can repeat every 5-10 minutes, or start infusion of 10 mcg/kg/min

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5
Q

Propofol onset/duration/metabolism/elimination

A

Onset w/ induction dose: 30 seconds
DOA w/ induction dose:5-15 minutes
Metabolized: hepatic and extra-hepatic (lungs), no active metabolite
Excreted: Kidney

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6
Q

Propofol Considerations

A 
no evidence that it should be avoided with egg or soy allergy 
contains sulfites
painful w/ injection
thrombophlebitis
bacterial infection risk
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7
Q

Propofol Systemic Effects

A 
CNS:
 Rapid onset and emergence
Raises seizure threshold
Reduces cerebral blood flow, CMRO2, ICP and IOP
No analgesia
Myoclonus may occur
Pulmonary:
Dose dependent respiratory depression
Infusion will decrease TV and increase RR
Decrease reflexes
Shifts CO2 response curve to the right
Bronchodilation

Cardiovascular:
Decreases BP r/t decrease SNS and vasodilation
Decrease myocardial contractility and SVR
Decrease venous tone - > lower preload

Metabolism and Elimination:
Hepatic and extra hepatic metabolism
Renally excreted
Propofol has the potential to change urine color (green or cloudy)

Muscles:
Does not prolong neuromuscular blockade but can offer adequate intubation conditions

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8
Q

Ketamine Class

A

phencyclidine derivative

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9
Q

Ketamine Uses:

A

GA induction, GA maintenance, MAC, analgesia , antidepressant

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10
Q

Ketamine MOA:

A

Non-competitive antagonist at NMDA receptor ion channels.
Ketamine blocks the open channel, inhibiting the excitatory response to glutamate.
Provides amnesic and potent analgesia.
Produces a “dissociative state” by depressing the cerebral cortex and thalamus and stimulating the hippocampus.
Bind w/ opioid, MAO, serotonin, NE, muscarinic and sodium channels
Ketamine inhibits neuronal sodium channels (producing a modest local anesthetic action) and calcium channels (causing cerebral vasodilatation)

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11
Q

Ketamine pre-medication

A

benzo and antisaligogue

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12
Q

Ketamine Dose/Onset/DOA for IV induction

A

1-2mg/kg
onset: 2-5minutes
DOA: 10-20 minutes (may require 1 hour for full orientation)

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13
Q

Ketamine IM induction dose/onset

A

4-6mg/kg

onset:20 minutes

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14
Q

Ketamine Sedation/multimodal dose

A

Sedation: 1-3mcg/kg/min or 0.5-1mg/kg boluses as needed

Multimodal infusion: 3-5 mcg/kg/min

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15
Q

Ketamine metabolism

A

P450 enzyme in liver, chronic ketamine use induces enzymes that metabolize it
Active metabolite: norketamine 1/3 as potent and renally excreted
Excretion: kidneys

least protein bound of all induction agents

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16
Q

Ketamine effects on organs

A

CNS:
Increased CMRO2, CBF, ICP
Dissociative
Analgesic
Depression
Associated with emergence delirium, nightmares and hallucinations
Benzodiazepines are an effective means of prevention
Risk factors: age > 15, female gender, personality disorder, dose > 2mg/kg
Cardiovascular:
SNS stimulant
Increased SVR, HR, myocardial O2 consumption, PVR
Mild myocardial depression
Respiratory:
Bronchodilator
Maintains respiratory rate
Preserves reflexes at low dose
Increased secretions, often paired with an antisialogue like glycopyrrolate
Ocular
Nystagmus

17
Q

Caution use of Ketamine in patients with:

A

HTN, angina, CHF, increased ICP, increased IOP, auditory/visual hallucinations, airway problems r/t increased secretions, emergence reactions

18
Q

Etomidate Class

A

Carboxylated imidazole derivative

Hypnotic

19
Q

Etomidate uses:

A

induction of anesthesia, considered CV stable and good for traumas

20
Q

Etomidate MOA

A

Binds to GABA-a receptor
Lower doses: potentiates GABA at receptors
Higher doses: directly stimulates the GABA receptor

21
Q

Etomidate dose/onset/duration

A
  1. 3mg/kg
    onset: 1 minutes
    doa: 5-15 minutes
22
Q

Etomidate metabolism

A

hepatic p450 enzymes and plasma esterases

extreted by kidneys and in bile

23
Q

Etomidate Organ Effects

A

CNS
Reduces intracranial pressure, cerebral blood flow, CMO2
Myoclonia likely related to an imbalance of excitatory and inhibitory pathways in the thalamacortical tract and can induce EEG seizure foci
No analgesia

Cardiovascular:
Hemodynamically stable
Minimal/no cardiac depression
Does not blunt sympathetic response to laryngoscopy

Pulmonary:
Brief hyperventilation followed by apnea
Mild respiratory depression (less than propofol)
No histamine release

Endocrine:
inhibits cortisol; adrenal suppression via suppression of 11-beta hydroxylase
GI – N/V in 30-40% of patients

Hematologic:
May induce acute intermittent porphyria

24
Q

Dexmedetomidine Class

A

selective alpha 2 adrenergic agonist

25
Q

Dexmedetomidine Uses:

A

MAC, induction, analgesia, prevention of emergence delirium

26
Q

Dexemedetomidine MOA

A

Centrally and peripherally alpha 2 adrenergic receptor agonist. Acts on alpha 2 receptors thereby producing sedation by decreasing sympathetic nervous system activity and the level of arousal.

Regulates the cardiovascular system by inhibiting norepinephrine release.

Reduces blood pressure and heart rate by decreasing the tonic levels of sympathetic outflow from the CNS and augmenting cardiac vagal activity.

27
Q

Dexemedetomidine Dosing

A

Procedural sedation: start 1mcg/kg over 10 minutes–> maintenance infusion 0.2- 1 mcg/kg/hr

28
Q

Dexemedetomidine Organ Effects

A

hypotension, bradycardia, minimal respiratory depression, analgesia, enhance neuraxial blockage, reduces emergence delirium in peds, reduces need for inhalation agent

29
Q

Dexmedetomidine metabolism/excretion

A

p450 enzyme, cleared by liver, inactive metabolites

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