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Top Drawer Medications > Induction Agents > Flashcards

Induction Agents Flashcards

1
Q

Propofol

Induction dose:

MAC Sedation Dose:

A

1-2.5 mg/kg IV

MAC — 25-75 mcg/kg/min

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2
Q

The general anesthesia sedation/maintenance dose of Propofol is:

A

25-200 mcg/kg/min

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3
Q

Indications for Propofol (5)

A

Induction and MAC
TIVA
Outpatient surgery and endoscopy
Antiemetic
Malignant Hyperthermia

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4
Q

MOA of Propofol:

A

GABA agonist

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5
Q

Cardiac and respiratory effects of Propofol:

A

Decreases CO, BP, SVR (slight decrease in HR until pt is asleep then increases to compensate for CV decreases)

dose-dependent respiratory depression
Decreased Vt
Increased RR (at maintenance doses)
Bronchodilator (direct effect on intracellular Ca++)

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6
Q

T or F: Propofol is a neuro protective drug

A

T

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7
Q

Propofol CNS effects:

A
  • neuroprotective — decrease CBF, CMRO2, and ICP & decreased SVR may cause decreased CPP
  • anticonvulsant
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8
Q

Contraindications of Propofol (3)

A

Allergies to soybean oil or soy products
Allergies to egg and egg products
Allergies to sulfite

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9
Q

Correct onset and duration of Propofol:

A

Onset: <1 min
**”30 seconds or so…”

Duration: dose and rate dependent

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10
Q

Metabolism of Propofol occurs in:

A

Hepatic

Kidney and lungs (account for ~ 30%)

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11
Q

Excretion of Propofol is via:

A

Renal System

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12
Q

unconventional use of propofol and MOA

A

10 mg IV for PONV and pruritis

MOA related to spinal cord suppression

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13
Q

T or F: propofol is good for WPW ablations because it has no AV or SN node depression

A

T

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14
Q

clinically when you should avoid propofol use

A

cardiac unstable or hemorrhaging

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15
Q

is propofol lipid soluble

A

yes

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16
Q

protein binding of propfol

A

97-99%

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17
Q

why can propofol injections be painful and what can you do to decrease it

A

glycerol; lidocaine 1 mg/kg

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18
Q

T or F: propfol has analgesic effects

A

F

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19
Q

T or F: Propofol is a chiral compound

A

F– not chiral

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20
Q

how is propofol partially reversed

A

physostigmine

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21
Q

induction dose of Ketamine:

IV
IM

A

1-2 mg/kg IV; 4-5 mg/kg IM

***in low dosing can be opioid sparing

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22
Q

infusion dose of Ketamine

A

1-2 mg/kg/hr

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23
Q

other name for Ketamine

A

Ketalar

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24
Q

other name for propfol

A

diprivan

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25
Q

indication for Ketamine (6)

A
  • induction
  • sedation
  • sedation for mentally challenged or non-compliant such as kids
  • CV collapse
  • “bad” epidural/spinal
  • Good for OB.
  • tamponade ***she didnt say this !?
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26
Q

contraindication of Ketamine (4)

A
  • Right heart dysfunction (decreases PVR)
  • increased ICP
  • Critically ill/shock pts ( catecholamine depletion r/t shock — will cause profound hypotension and unopposed direct myocardial depression)
  • psych patients (will make them hallucinate)
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27
Q

MOA of Ketamine (3)

A
  • noncompetitive NMDA antagonist that blocks glutamate
  • stimulates the SNS: inhibits the reuptake of norepi
  • dissociative anesthesia — dissociation btwn thalamocortical and limbic system
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28
Q

CV system effects of Ketamine

A
  • increase BP, HR, CO, PAP, CVP, CI
  • increases myocardial O2 requirements
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29
Q

in what CV patient should you be especially cautious of using Ketamine

A

pt with severe RIGHT heart dysfunction

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30
Q

Respiratory system effects of Ketamine (4)

A
  • minimal depression
  • maintain upper airway reflexes
  • increased oral secretions (effects on muscarinic receptors)
  • bronchodilator (used in bronchospasm dilator)
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31
Q

Neuro system effects of Ketamine (5)

A
  • cerebral dilator (increased ICP)
  • potential to produce myoclonic activity (usually considered an anticonvulsant though)
  • prolongs and enhances effects of NMBDs
  • emergence delirium
  • Hallucinogenic: phencyclidine derivative
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32
Q

other system effects of Ketamine

A
  • increased lacrimation and salivation –> premedicate with anticholinergic
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33
Q

what are a few clinical judgments necessary for Ketamine? (4)

A
  • used in OB (NOT preeclamptic)
  • ketamine dart 3-4 mg/kg for mentally challenged
  • not good for brain lesions d/t increased ICP
  • MAY be used as a last resort for status epilepticus
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34
Q

onset of Ketamine

IV
IM

A

IV- 30 seconds
IM 2-4 minutes

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35
Q

duration of Ketamine
IV
IM

A

IV 10-15 min
IM 15-25 min

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36
Q

metabolism of Ketamine

A

hepatic by demethylation via CYP 450

*active metabolite, Norketamine, is 1/3-1/5 as potent

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37
Q

excretion of Ketamine

A

Renal

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38
Q

T or F: Ketamine provides analgesia w/o airway compromise

A

T

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39
Q

more potent stereoisomer of Ketamine

A

S (+)

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40
Q

T or F: for Ketamine, there is a functional dissociation between thalamocortical and limbic systems

A

T

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41
Q

protein binding of Ketamine

A

only anesthetic that has low protein bind (12% or 20% depending on source)

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42
Q

describe the cataleptic state of Ketamine

A

pt eyes remain open with slow nystagmic gaze

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43
Q

other name for Thiopental

A

pentathol

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44
Q

induction dose of Thiopental

A

3-5 mg/kg IV

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45
Q

how should you adjust the induction dose of Thiopental for elderly

A

reduce by 30%

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46
Q

indications for Thiopental (4)

A
  • induction/sedative
  • hypnotic
  • anticonvulsant
  • treatment of ICP (Neuro cases)
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47
Q

contraindications of Thiopental (3)

A
  • Acute intermittent Porphyria
  • variegate Porphyria
  • status asthmaticus (**d/t histamine release)
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48
Q

MOA of Thiopental (2)

A
  • activates GABA — short acting barbituate
  • decreases RAS (small histamine release)
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49
Q

CV effects of Thiopental

A

Hypotension

Depresses myocardium and relaxes vascular smooth muscle

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50
Q

respiratorey effects of Thiopental

A

resp depression

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51
Q

Neuro effects of Thiopental (3)

A
  • potent cerebroconstrictor
  • decreased CBF
  • decreased ICP
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52
Q

GI effects of Thiopental

A

N/V

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53
Q

T or F: Thiopental has analgesic effects

A

F- may actually lower pain threshold; thus increasing sensitivity to pain

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54
Q

onset of thiopental

A

30-60 seconds

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55
Q

duration of Thiopental

A

5-30 min

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56
Q

metabolism of Thiopental

57
Q

half life of Thiopental

58
Q

protein binding of Thiopental

A

80%

** its actually 72-86%**

59
Q

what does Thiopental precipitate with

A
  • lidocaine
  • roc
  • succs

THIs LIghter Really Succs

60
Q

important things to know about Thiopental (5)

A
  • extravation= necrosis
  • accidental arterial injection= severe vasoconstriction
  • sulfur on 2nd C atom
  • “hangover feeling”
  • pt can experience garlic/onion taste
61
Q

other name for etomidate

62
Q

induction dose of etomidate

A

0.2-0.3 mg/kg

63
Q

infusion dose of etomidate

A

5-20 mcg/kg/min

64
Q

indications for etomidate (2)

A
  • induction
  • procedural sedation
65
Q

MOA of etomidate (3)

A

GABA agonist (increases Cl- influx, hyperpolarizing cell)
Short acting non-barbituate hypnotic
Depresses RAS

66
Q

CV and respiratory effects of etomidate

A

CV- minimal effects
resp- depression

67
Q

neuro effects of etomidate

A
  • potent cerebroconstrictor decreases CMR, CBF, ICP
  • myoclonus decrease with opioids
68
Q

GI effects of etomidate

69
Q

other system effects of etomidate

A
  • adrenocorticol supression
70
Q

in what type of patient is etomidate a good choice for

A
  • cardiac patients with low EF
71
Q

what procedures/ patients should you use clinical judgment for use of etomidate

A
  • ECT (prolong seizure duration)
  • trauma
  • elderly patients
72
Q

onset of etomidate

A

30-60 seconds

73
Q

duration of etomidate

A

3-5 min

Pharm says 5-10 minutes

74
Q

metabolism of etomidate

A

hepatic and plasma ester hydrolysis

75
Q

excretion of etomidate

A

renal (80%)
Bile (20%)

76
Q

protein binding of etomidate

77
Q

more potent isomer of etomidate

78
Q

does etomidate have hypnotic and analgesic effects

A

hypnotic- yes
analgesic- no

79
Q

other name for dexmedetomidine

80
Q

procedural sedation dexmedetomidine:

For sedation:
For infusion:

A

Sedation: 0.5-1 mcg/kg over 10 min

Infusion: 0.3-0.7 mcg/kg/hr

81
Q

awake fiberoptic intubation and infusion dose of dexmedetomidine

A

intubation: 1 mcg/kg over 10 min
infusion: 0.7 mcg/kg/hour until intubated

82
Q

indications for dexmedetomidine (4)

A
  • pediatrics
  • analgesia (acts on mu, delta, kappa receptors)
  • procedural/Postop sedation
  • awake fiberoptic intubation
83
Q

contraindications for dexmedetomidine

A
  • AV block
  • 1st degree HB
84
Q

MOA of dexmedetomidine

A
  • highly selective potent central acting alpha-2 adrenergic agonist (inhibit release of norepinephrine)
85
Q

CV effects of dexmedetomidine

A
  • bradycardia
  • sinus arrest
  • hypotension
  • rebound HTN

Tx: w/ atropine/ephedrine/volume

86
Q

respiratory effects of dexmedetomidine

A

Minimal depression

  • less vent depression than other agents
  • bonus can decrease minute ventilation
87
Q

onset and peak of dexmedetomidine

A

onset: 5-10 min
Peak: 15-30 min

88
Q

duration of dexmedetomidine

A

1-2 hours (dose-dependent)

89
Q

metabolism of dexmedetomidine

90
Q

excretion of dexmedetomidine

91
Q

protein binding of dexmedetomidine

92
Q

dexmedetomidine provides what CNS dose dependent effects (3)

A
  • analgesia
  • anxiolysis
  • sedation
93
Q

Which is more alpha selective:
dexmedetomidine or clonidine

A

dexmedetomidine

94
Q

the hypnotic efects of dexmedetomidine occur in:

A

locus coeruleus

95
Q

where do the analgesic effects of dexmedetomidine occur

A

level of spinal cord

96
Q

T or F: can develop tolerance and dependence of dexmedetomidine

97
Q

What effects does dexmedetomidine have on the CYP 450 system

A

inhibitory properties that can increase plasma concentrations of opioids

98
Q

another name for methohexital

99
Q

induction dose (and concentration) of methohexital

A

1-1.5 mg/kg

Concentration: 500 mg vial reconstituted with 50 cc NS (1% solution —> 10 mg/cc)

100
Q

indications for methohexital (3)

A
  • ECT
  • Endo
  • very short procedures
101
Q

contraindications for methohexital

A
  • acute intermittent porphyria
  • variegate porphyria
102
Q

MOA of methohexital

A

enhances GABA— rapid ultrashort acting barbiturate

103
Q

system effects of methohexital (4)

A
  • skeletal muscle hyperactivity
  • deep sedation
  • pain on injection
  • Lowers seizure threshold
104
Q

methohexital useful in what procedures clinically and why

A
  • ECT–> lower seizure threshold
  • Endo–> used when shortage of propofol (very short procedures).
105
Q

onset and duration of methohexital

A

onset: < 1 min
duration: 5-7 min

106
Q

metabolims of methohexital

107
Q

excretion of methohexital

108
Q

protein binding of methohexital

109
Q

what med should you be catious of when using methohexital

A

atropine– it precipitates with it

110
Q

chemical property of methohexital

A

oxygen retained on the 2nd C atom

111
Q

In what 6 groups should we use propofol cautiously and how should each groups dose be adjusted? (6)

A
  1. Children — Need more large Vd and quicker clearance= need more
  2. Chronic ETOH — Need more d/t enzyme abuse
  3. Obese — Depends base dosing on lean body weight
  4. CV disease — Need less d/t propofol decreasing SVR
  5. Trauma/hypotensive/bleeding — Need less d/t the decrease in SVR, BP, CO, SV
  6. Elderly — Need less decreased sensitive, prolonged effects d/t decreases CO and clearance
112
Q

Dose of lidocaine

A

0.5-1.5 mg/kg (dose depend on pt and provider)

113
Q

Why is lidocaine used on induction (4)

A
  • suppress coughing reflex during laryngoscopy/intubation/EGDs
  • reduce airway responsiveness to noxious stimuli
  • reduce pain from IV injected agents
  • Can attenuate the intracranial hypertensive response to laryngoscopy/intubation.
114
Q

Lidocaine might increase hypotensive effects of

A

Sedative-hypnotic agents

115
Q

Why should you use caution when administering lidocaine to cardiac patients

A
  • indirect evidence that it can attenuate intracranial hypertensive response to laryngoscopy and intubation
  • lidocaine (1.5 mg/kg) given 3 min before intubation suppresses cough reflex and attenuates increased airway resistence resulting from laryngoscopy and ETT intubation
116
Q

How can you prevent emergence delerium from ketamine

A
  • low lights
  • quiet room
  • versed (2 mg as pretreatment)
117
Q

T or F: KEtamine causes intense analgesia

118
Q

Ketmine dose for bronchospasms

A

0.2-1.0 mg/kg IV

119
Q

Active metabolite of ketamine and how “active “ is it?

A

Norketamine

1/3-1/5 as potent as ketamine

120
Q

Level of histamine release from thiopental use

A

“Some”

121
Q

How can you decrease myoclonic movements with etomidate

122
Q

How can you treat Precedex induced hypotension

A

Atropine
Ephedrine
Volume

123
Q

T or F: Methohexital has anticonvulsant activity

A

F — does not have anticonvulsant activity (lowers seizure threshold)

124
Q

For intermittent IV use of methohexital, how should it be reconstituted

A

Into 1% (10 mg/cc)

125
Q

T or F: Methohexital has a slow redistribution

A

F— RAPID

126
Q

____________ is the shortest-acting barbiturate and (does/does not) have anticonvulsant activity. It (lowers/increases) the seizure threshold.

A

Methohexital

Does not

Lowers (this is why its good for ECT)

127
Q

Etomidate is a ____________ derivative

A

Carboxylated imidazole

128
Q

Ketamine has (low/high) lipid solubility

129
Q

How do we dose ketamine when using for a “bad spinal/epidural”

A
  1. 2 mg Versed
  2. Ketamine in 10-20 mg doses at a time until pt is unresponsive to glabellar tap, still breathing, not screaming
  3. If they even bat an eyelash, immediately give 10 mg more
  4. Repeat until procedure is finished
130
Q

Lidocaine dose

What do we typically give and when must we adjust it?

A

1 mg/kg (range is 0.5-1.5 mg/kg)

Typically give 100 mg of 2% solution (5 cc); adjust this for both patients weighing less than 60 kg, as well as hemo unstable

131
Q

Why don’t we mix propofol and lidocaine in same syringe

A

After 20 mins, the effect of Propofol are negated and lipid emulsion broken up (risk for embolism)

132
Q

Propofol:
N/V rescue dose-
N/V background infusion dose -
What MOA is this?

A

10-15 mg
10-20 mcg/kg/min

Direct effect on CTZ

133
Q

Cause of PRIS and how is it recognized clinically?

A

Occurs with propofol doses 4 mg/kg/hr > 48 hours or 67 mcg/kg/min

Bradycardia, EKG changes, Arrhythmias

134
Q

For which patients would we use TIVA rather than inhalational GA

A

History of PONV or MH

135
Q

How do we know pt is unconscious/sedated during TIVA if they are muscle relaxed?

A

Use BIS (40-60 is ideal for GA)

136
Q

How does etomidate cause adrenocortical suppression and for how long?

A

Inhibit 11 B hydroxylase enzyme (Effects last 4-8 hours after induction dose of etomidate)

137
Q

CNS Ketamine effects

A
  • potent cerebral vasodilator
  • increase CBF by 60-80% (hyperventilate to attenuate effects)
  • relatively C/I in pt with elevated ICP
138
Q

Propofol S/E (3)

A
  • injection pain (d/t glycerol)
  • allergies/anaphylaxis (d/t phenyl nucleus and di-isopropyl side chain)
  • PRIS (bradycardia, ekg changes, arrhythmias)

Top Drawer Medications (13 decks)

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