INDUCTION AGENTS

Question 1

Etomidate

Answer 1

• Induction/Bolus Dose Range: 0.2-0.4 mg/kg IV
• Onset: 30-60 sec
• Duration: 3-10 minutes (quick on quick off d/t uptake into brain and redistribution to fat/muscle = decrease in blood concentration; not d/t metabolism!)
• o C/I: caution with adrenal insufficiency(Addison’s), Acute Intermittent Porphyria (increases ALA synthase making more precursors for ineffective hem conversion = build up toxic), seizure hx, sepsis and hemorrhage (HPA axis).
  o Precautions: 35% propylene glycol→pain at injection site. Rapid injection can cause brief apnea

Question 2

· Propofol

Answer 2

-Induction dose: Adults: 2-2.5 mg/kg, children: 2.5 -3.5 mg/kg IV
-GA Infusion Dose: 100-200 mcg/kg/min
-Sedation Infusion Dose: 25-75 mcg/kg/min
* Onset: 30 seconds
* Duration: 5-10 minutes (quick on quick off d/t uptake into brain and redistribution to fat/muscle = decrease in blood concentration; not d/t metabolism!)
* o Precautions: Pronounced decrease in systemic BP, profound bradycardia and asystole, propofol infusion syndrome “inhibition of long chain fatty acids from moving into cell and having oxidative phosphorylation (aerobic resp) occur” (metabolic acidosis, rhabdo, arrhythmias, lipemia), pain on injection d/t being an alkylphenol, allergic rxn usually not from egg yolk lecethin allergies but instead sulfide propofol preservatives (still safe to give if they have allergy); bacterial growth d/t additives = discard syringe after 6 hours.
-Black Box Warning: severe bradycardia in children and elderly

Question 3

· Ketamine

Answer 3

-Induction Dose: 1-2 mg/kg
-Ketamine Dart (IM Dose): 2-4 mg/kg
-GA Infusion Dose: 30-90 mcg/kg/min
-Intense Analgesia: 0.5mg/kg after induction and then 0.25 mg/kg Q1H; “We use about 10-20 mg after induction, then 10 mg Q1H, but not on last hour before closing”
* Onset: 1 min IV/ 4 min IM
* Duration: 5-10. Min IV / 12-25 min IM (overall up to 60 min for full recovery)
-(quick on quick off d/t uptake into brain and redistribution to fat/muscle = decrease in blood concentration; not d/t metabolism!)
o C/I: Systemic/pulm HTN, increased ICP; MAOIs, methamp, cocaine- (increases epi), Ca2+ depletion, Neuro trauma (CNS stim), SNS depression.
o Precautions: HoTN c volatiles d/t (blunt SNS response); inhibits free Ca2+ conc = inc block; prolonged block c succ d/t dec plasma cholinesterase; unexpected drops in SBP/CO with depleted catecholamines; inhibit plt aggregation; Emergence delirium (give versed IV prior); allergic reaction via Benzethonium Cl preservative to make water soluble

Used with which pts: Acute hypovolemic pts, asthmatic/bronchospasm, MH patients, CAD ‘cocktail’ patient, pediatric induction (IM), burn pt with dressing changes, reversal of opioid tolerance, restless leg syndrome (PO)