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Clinical Prep 2024 > Induction Agents > Flashcards

Induction Agents Flashcards

1
Q

What organs utilize the most blood supply?
What organs utilize the least?
What organs are in between these two groups?

A
  • Vessel-rich group = 75% CP (brain, heart, liver, kidneys)
  • Skeletal muscles & skin = 18% CO
  • Fat = 5% CO
  • Bone, tendons, & cartilage = 2% CO
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2
Q

What are the one-word (ish) summaries of the four stages of anesthesia?

A
  1. Analgesia
  2. Delirium
  3. Surgical Anesthesia
  4. Medullary paralysis (death)
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3
Q

What reflexes are we suppressing during stage 1 anesthesia?
If stage 1 anesthesia is maintained, what is it called?

A
  • Coughing, swallowing, and gagging reflexes (lower airway reflexes)
  • Conscious sedation
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4
Q

During induction, when would one most likely see laryngospasm?

A
  • Stage 2
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5
Q

During emergence, when would one most likely need to be re-intubated?

A
  • Stage 2
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6
Q

For Propofol, what are the doses for:
1. Induction
2. Maintenance
3. Conscious sedation

A
  1. Induction = 1.5 - 2.5 mg/kg IV
  2. Maintenance = 100 - 300 μg/kg/min
  3. Conscious sedation = 25 - 100 μg/kg/min
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7
Q

What is the most common concentration of a 1% solution?

A
  • 10mg/mL
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8
Q

What are the inactive ingredients in propofol? Why is one particularly important?

A
  • 1.2% Lecithin (from egg yolks) can cause anaphylaxis with egg allergies.
  • 2.25% glycerol (pain)
  • 10% soybean oil
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9
Q

What are the disadvantages of propofol’s inactive ingredient composition?

A
  • ↑ bacterial growth
  • ↑ plasma triglycerides with prolonged infusions
  • Pain on injection
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10
Q

What is the mechanism of action of propofol?

A
  • GABA receptor modulator that increases Cl⁻ conductance.
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11
Q

How does propofol cause immobility through spinal cord-depression?

A
  • Trick question. Immobility from propofol is not from drug-induced spinal cord depression.
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12
Q

What are the clearance characteristics of propofol?

A

The clearance of propofol is primarily through hepatic metabolism, with minor contributions from renal clearance and pulmonary elimination.

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13
Q

What metabolizes propofol?

A
  • CYP450 and UGT1A9
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14
Q

What drug is the induction drug of choice?

A

Propofol

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15
Q

What is the induction dose of propofol in adults? Children?

A
  • Adults: 1.5-2.5 mg/kg IV
  • Pediatrics: higher doses due to larger central volume and clearance rate.
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16
Q

What plasma propofol levels would correlate with unconsciousness?
What about awakening?

A
  • Unconscious: 2 - 6 μg/mL
  • Awake: 1 - 1.5 μg/mL
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17
Q

What is the conscious sedation dose of propofol?

A
  • 25 - 100 μg/kg/min
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18
Q

What is the sub-hypnotic dosing for propofol?

A
  • 10 - 15 mg IV, followed by 10 mcg/kg/min
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19
Q

What is the anti-pruritic dosing of propofol?

A
  • 10 mg IV
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20
Q

What are propofol’s effects on CMRO₂, CBF, and ICP?

A
  • ↓ CMRO₂, CBF, and ICP
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21
Q

Large doses of propofol may ______ cerebral perfusion pressure.

A

decrease

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22
Q

Though propofol will not produce seizures, it will produce _______.

A

myoclonus

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23
Q

Between thiopental, propofol, and isoflurane, which is the least EEG suppressive?

A
  • Propofol
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24
Q

What severe condition(s) can occur with prolonged propofol infusions?

A
  • Hepatocellular injury or Propofol Infusion Syndrome.
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25
Q

What is the worst side effect in children who have propofol infusion syndrome?

A
  • Severe, refractory, fatal bradycardia
26
Q

What relatively benign condition(s) can occur from prolonged propofol infusions?
Why does this happen?

A

Green and cloudy urine from phenols and uric acid crystals.

Neither alters renal function.

27
Q

What is Propofol Infusion Syndrome?

A
  • Metabolic acidosis thought to occur from poisoning of electron transport chain and impaired oxidation of fatty acids.
28
Q

What percentage of etomidate is propylene glycol? What is the result of this?

A
  • 35% propylene glycol resulting in pain on injection.
29
Q

Which induction agent can be given without an IV? How is this?

A

Etomidate - can be given sub-lingual.

30
Q

Why does etomidate have a low incidence of myoclonus?

A
  • Trick Question. Etomidate has a high incidence of myoclonus, just like all other induction agents.
31
Q

What is the induction dosage for etomidate?

A
  • 0.3 mg/kg
32
Q

What is the best use for etomidate?

A
  • Induction for unstable cardiac patients.
33
Q

What needs to be used concurrently with etomidate when performing a laryngoscopy? Why?

A
  • Opioids, etomidate has no analgesic effects.
34
Q

What is Etomidate’s most common side effect?
How often does this occur?

A
  • Involuntary Myoclonic Movements ( 50 - 80 %) of administrations.
  • Also PONV (30%)
35
Q

Etomidate has a dose dependent inhibition of the conversion of cholesterol to _________.
What does this mean clinically?

A
  • Cortisol
  • Etomidate decreases SNS capability to respond to stress (longer vent times, hypotension, etc.)
36
Q

How long does adrenocortical suppression with etomidate last?
What two pathologies would cause you to hesitate before giving etomidate?

A
  • 4-8 hours.
  • Sepsis & hemorrhage (anything where you need an intact cortisol response).
37
Q

Though etomidate is great for cardiac patients, what condition can result in significant hypotension if not treated prior to induction?

A
  • Hypovolemia
38
Q

Histamine release via etomidate is mediated through what?

A
  • Trick question. Etomidate does not release histamine.
39
Q

What type of drug is ketamine?
What type of anesthesia does it produce?
What two properties does it possess?

A
  • Phenycyclidine derivative; NMDA receptor antagonist (PCP; “angel dust”)
  • Dissociative anesthesia
  • Amnestic & intense analgesia
40
Q

What are ketamine’s two greatest advantages over propofol or etomidate?

A
  • No pain at injection (no propylene glycol)
  • Profound analgesia at sub-anesthetic doses.
41
Q

What signs and symptoms does dissociative anesthesia (ketamine) produce?

A

“Zonked” state

  • Non-communicative but awake
  • Hyptonus & purposeful movements
  • Eyes open but “no one’s home”.
42
Q

What are the two greatest disadvantages of ketamine?

A
  • Emergence delirium
  • Abuse potential
43
Q

What is Benzethonium Chloride? What is it’s relevance?

A
  • Ketamine preservative that inhibits ACh receptors
44
Q

Differentiate S(+)Ketamine vs R(-)Ketamine.

A

S-Ketamine (left-handed isomer) is essentially better.

  • More intense analgesia
  • ↑metabolism & recovery
  • Less salivation
  • Lower emergence delirium
45
Q

What is Ketamine’s main mechanism of action?

A
  • Non-competitive inhibition of NMDA (N-methyl-D-aspartate) receptors by inhibiting pre-synaptic release of glutamate.
46
Q

What is Ketamine’s time of onset? (IV & IM)
When would this drug be utilized IM?

A
  • IV: 1 min
  • IM: 5 min (mostly for pediatric patients)
47
Q

In what patient population is ketamine tolerance most often seen?

A

Burn patients

48
Q

What is the induction dose of ketamine IV?

A
  • 0.5 - 1.5 mg/kg IV
49
Q

What is the maintenance dosing of ketamine?

Give both IM and IV dosings.

A
  • 0.2 - 0.5 mg/kg/hr IV
  • 4 - 8 mg/kg IM
50
Q

What is the subanesthetic/analgesic dose of ketamine?

A
  • 0.2 - 0.5 mg/kg IV
51
Q

Ketamine is a potent sialagogue. What does this mean for your clinical practice?

A
  • Manage excessive secretions during intubation & watch for coughing/laryngospasm.
  • Give Glycopyrrolate prior
52
Q

What “other systems” effects does ketamine have?

A
  • Non-depolarizing NMBs enhancement.
  • Succinylcholine prolongation via plasma cholinesterase inhibition.
  • PLT aggregation inhibition
53
Q

Which induction agent has the highest analgesic properties?

A
  • Ketamine
54
Q

Why would ketamine be a decent induction drug for an OSA patient? Why not?

A
  • Preservation of upper airway reflexes & ventilatory function.
  • Sialagogue.
55
Q

What should be administered with etomidate to prevent involuntary myoclonic movements?

A

Fentanyl 1-2 μg/kg IV

56
Q

What drug and dosing of said drug should be used to treat excessive salivary secretions from ketamine administration?

A

Glycopyrrolate: 0.2mg

57
Q

Why does ketamine prolong succinylcholine’s effects?

A

Ketamine is a plasma cholinesterase inhibitor.

58
Q

What is the induction dose of succinylcholine?

A

1 - 1.5 mg/kg

59
Q

What is the induction dose of rocuronium?

A

0.6 - 1.2 mg/kg

60
Q

What is the induction dose of cisatracurium, vecuronium, and pancuronium?

A

0.1 mg/kg

61
Q

What is the induction dose of Fentanyl?

A

1.5 - 3 mcg/kg

62
Q

What is the induction dose of Lidocaine?

A

1 mg/kg (100 mg max)

Clinical Prep 2024 (11 decks)

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