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Anesthesia Pharmacology > Induction drugs > Flashcards

Induction drugs Flashcards

Test 2

1
Q

What is the difference between a sedative & a hypnotic?

A

A hypnotic induces sleep while a sedative induces a state of calm

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2
Q

What drugs do we use for anxiolytics? If we don’t have these, what is an alternative?

A

Benzos

Small doses/titration of tranquilizers/induction agents
Ex) 1-2cc propofol

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3
Q

Sedative-hypnotics have reversibly depresses what? What is this caused by?

A

Depresses CNS activity –> decreases sympathetic effects

Synergistic effects

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4
Q

Monitored anesthesia care is the same thing as ___________ (2 things)

A

Conscious sedation
Procedural sedation

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5
Q

What is the definition of monitored anesthesia care (MAC)?

A

The administration of both sedatives and analgesics to induce a depressed level of consciousness, allowing patients to tolerate unpleasant procedures and enabling clinicians to perform procedures effectively

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6
Q

When using a CVC/PICC line, where does the blood flow through 1st? PIV?

A

CVC/PICC: Superior vena cava

PIV: Inferior vena cava

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7
Q

After blood flow through the heart, what is the order of blood flow for anesthesia drugs? What is the percentage? What organs are in each sections?

A

Vessel rich group (75%) –> muscle group (18%) –> fat (5%) -> vessel poor group (2%)

Vessel rich: brain
heart
liver
kidney

Muscle: skeletal muscle
skin

fat: just fat

vessel poor: bone
tendon
cartilage

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8
Q

What is the exception of anesthesia drugs going to the brain first?

A

local/regional anesthesia

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9
Q

Which induction agents have analgesia components?

A

Propofol: high doses
Ketamine

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10
Q

What receptor does ketamine attach to?

A

NMDA receptor

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11
Q

What are the components of general anesthesia?

A

HAMSA (means good luck!)

Hypnosis
Analgesia
Muscle relaxation
Sympatholysis
Amnesia

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12
Q

What does sympatholysis mean?

A

Preventing an increase in HR/BP

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13
Q

What is the most dangerous stage of anesthesia?

A

Stage 2

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14
Q

What stage do we want to perform surgery in in anesthesia?

A

Stage 3

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15
Q

What are the 4 airway reflexes?

A
  1. Sneezing.
  2. Coughing.
  3. Swallowing.
  4. Gagging.
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16
Q

What is the lightest level of anesthesia?

A

Stage 1

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17
Q

What is the last sense to be lost during induction?

A

hearing

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18
Q

When should all of your airway reflexes be present? Absent? Diminished?

A

Present: stage 1

Absent: stage 3

Diminished: stage 2

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19
Q

What stage do we want to extubate in? Why?

A

Stage 1

Patient can maintain protective reflexes/airway

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20
Q

What is stage 1 of anesthesia? What is it characterized by?

A

Analgesia

initiation of an anesthetic –> loss of consciousness

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21
Q

T/F: you are able to open your eyes on command and breathe normally in stage 1 of anesthesia

A

T

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22
Q

How long does stage 2 of anesthesia last?

A

5-15 seconds

max 30 secs

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23
Q

What is stage 1 of anesthesia? What is it characterized by?

A

Delirium

Loss of consciousness –> onset of rhythmicity of vital signs

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24
Q

What are undesirable SE of stage 2 of anesthesia?

A

-Release of Epi/NE –> undesirable CV instability –> increased HR

dysconjugate ocular movements

Laryngospasms

emesis

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25
Q

When do we go into phase 3 from phase 2?

A

The time of onset of the drug given

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26
Q

What do we not want to do during phase 2? why?

A

We don’t want to stimulate the pt at all –> can increase excitement

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27
Q

What is stage 3 of anesthesia? What is it characterized by?

A

Surgical

Absence of response to surgical incision or laryngoscopy

Depression in all elements of nervous system function (HAMSA)

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28
Q

What stage of anesthesia? can you intubate in?

A

Stage 3

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29
Q

What is stage 4 of anesthesia? What is it characterized by?

A

Medullary Paralysis

Sensation of spontaneous, respirations, and major cardiac reflexes

BP and HR decrease = no compensatory measures

All reflexes are absent
-Flaccid paralysis
-Marked hypotension with weak irregular pulse
-Main to death

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30
Q

What causes you to go into stage 4 of anesthesia?

A

Over anesthetizing the patient

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31
Q

During emergence what happens during stage 3 of anesthesia

A

Reversal agents are given

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32
Q

During emergence what happens during stage 2 of anesthesia

A

-Assuring pt is able to protect airway & follow commands
-pt has adequate tidal volumes

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33
Q

Inhalation induction takes _________ in pediatrics. What are the time frames for induction? Emergence?

A

longer

stage 1: 5-10 min
stage2: 2-3 min

Even more prolonged in emergence

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34
Q

What is the most common Barbiturate?

A

Thiopental (pentothal)

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35
Q

What are barbiturates derived from?

A

barbituric acid

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36
Q

Which drug is used in the lethal injection cocktail?

A

Thiopental (pentothal)

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37
Q

What is the gold standard induction drug? Why is this this important?

A

Barbiturates

Need to understand how this drug works bc we use this as a standard comparison tool for other drugs

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38
Q

T/F: We use barbiturates during induction

A

F

Other countries do though, just not the US

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39
Q

What are barbiturates MOA? What are the additional receptors barbiturates work on?

A

GABA activitiy on the GABAA channel

Addtl receptors: Glutamate
-adenosine
-neuronal nicotinic Achl

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40
Q

Barbiturates are a cerebral ____________. What does this mean? What does this decrease your risk of?

A

Vasoconstrictor

Decrease CBF & CMRO2 –> decreased metabolism and need for O2 in the brain

Decreases risk of CVA/stroke

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41
Q

How much does barbiturates decrease CMRO2 by?

A

55%

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42
Q

T/F: barbiturates has an analgesia component

A

F

Some sort of pain medication has to be given in conjunction with this

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43
Q

T/F: Volatile agents are couple. What does this mean?

A

F

Increase CBF = decrease CMRO2
(& vice versa)

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44
Q

What are barbiturates pharmacokinetics?
Onset.
Redistribution.

A

Onset: 30 secs
-rapid onset & awakening dt rapid uptake

Redistribution/reversal:
-5 mins: 1/2 dose
-30 mins: 10%

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45
Q

Describe what happens with barbiturates during a prolonged infusion

A

lengthy context-sensitive half-time dt groups/organs acting as a reservoir –> prolong effects after dc of infusion.

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46
Q

Describe barbiturates distribution in the skeletal muscles

A

-Initial site of redistribution from VRG

-Equilibrium at 15 mins to plasma (within 15 minutes, the drug concentration in the plasma/VRG declined, and is now distributing into lower-perfusion tissues)

-Decreased perfusion: shock dt decreased CO
-Elderly dt decreased muscle mass

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47
Q

Describe barbiturates distribution in the fat. What consideration should we have for this?

A

-acts as a reservoir dt barbs being highly lipid soluble

Considerations:
Dose based on LEAN body weight/ideal body weight (IBW) to avoid cumulative effects with large doses

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48
Q

We use _______ to dose barbiturates

A

IBW
Lean body weight

49
Q

Barbiturates are metabolized ____% in the liver, and excreted in the ______

A

99%

kidney

50
Q

Barbiturates half time is ______ in pediatric pts

51
Q

Barbiturates protein binds to ________. What is the percentage? Why is this important?

A

Albumin

70-85%
-Being this highly protein bound makes the plasma act as a second reservoir –> when it unbinds –> sedative effects

52
Q

What is the effect on redistribution if the drug has a high protein binding capacity?

A

Longer duration of action

53
Q

What is the difference between the ionized and the non-ionized form of barbiturates?

A

Non-ionized:
-More lipid soluble
-Favors acidosis
-Hangover effect

Ionized:
Less lipid soluble
-favors alkalosis
-lingers intravascularly –> attaches to albimun

54
Q

What are previous uses of barbiturates?

A

Grand mal seizures
-pre-medication
-uncooperative/young patient (rectal)
-increased ICP
-cerebral protection
-induction

55
Q

Which isomer is more potent in barbiturates?

A

S(-) I am more is much more potent than R(+)

56
Q

T/F: barbiturates only exist in racemic mixtures

57
Q

What are the barbiturates names?

A

Oxybarbiturates:
Methohexital
Phenobarbital
Pentobarbital

Thiobarbiturates:
Thiopental
Thiamylal

58
Q

Which barbiturate is used for electroconvulsive therapy (ECT)?

A

Methohexital

59
Q

What is the dose for Thiopental (Pentothal)?

A

4 - 5 mg/kg IV

60
Q

What are the pharmacokinetics for Thiopental (Pentothal)? Redistribution/reversal; halftime; fat/blood partition coefficient

A

Redistribution/reversal: 30 min –> 10% brain
-rapid redistribution

halftime: longer than methohexital dt being more lipid soluble –> lingers in fat compartment longer

fat/blood partition coefficient: 11 (# high –> longer DOA) –> calculate dose on IBW

61
Q

What is partition coefficient?

A

Describes the distribution of a given agent at equilibrium between two substances at the same temperature pressure and volume

Describes the distribution of an anesthetic between blood and gas at the same partial pressure
-a higher blood-gas coefficient correlates with higher solubility of anesthetic in blood, and thus slowing the rate of induction

62
Q

At normal pH, _____% of Methohexital (Brevital) is non-ionized and _____% of Thiopental (Pentothal) is non-ionized

63
Q

Oxybarbiturates have oxygen at the _________ position.

64
Q

How does Thiobarbiturates compare to oxybarbiturates?

A

Oxygen in the 2nd position replaced with a sulfur –> makes more lipid soluble –> greater hypnotic potency

65
Q

Increasing body fat = _____ blood volume. Why?

A

decreased

adipose tissue has decreased blood supply

66
Q

How does Methohexital (Brevital) affect seizure activity? What are the AE?

A

Decreases seizure threshold –> induces seizure activity in pts undergoing temporal lobe resection

AE: Excitatory phenonmena –> Myoclonus & hiccoughs

67
Q

How can you prevent the excitatory phenomena associated with Methohexital (Brevital)?

A

Pretreat w/ opioids

68
Q

How do you calculate IBW?

A

Men:
52 + (1.9Kg x inches over 5ft)

Women:
49 + (1.7Kg x inches over 5ft)

69
Q

What is the dose for Methohexital (Brevital)?

A

Induction: 1.5 mg/kg IV

Per rectum (PR): 20-30 mg/kg

70
Q

Methohexital (Brevital) ___________ seizure duration by _______% in ECT patients compared to Etomidate.

A

Decreases

35-45%

71
Q

Continuous infusion of Methohexital (Brevital) puts pt at risk of what?

A

1/3 pts experience post op seizures

72
Q

What are the CVS SE of barbiturates?

A

Lack of baroceptors: hypovolemia
CHF
Beta blockade

Induces histamine release:
usually asymptomatic

73
Q

What happens if the Thiopental (Pentothal) histamine release induces in anaphylactoid response?

A

This is a risk with previous exposure

Epi/Vaso –> 1mg in 10cc –> give 1 cc at a time.

74
Q

What are normal CV effects of Thiopental (Pentothal)?

A

Transient 10-20mmHg decrease in SBP

Transient 15-20 increase in HR

75
Q

What are the SE of Barbiturates on ventilation?

A

Dose dependent:
depresses ventilatory centors (medullary/pontine = medulla/pons) –> making them less sensitive to CO2

Return to spontaneous ventilation:
characterized by slow frequency (decreased RR) & decreased tidal volumes (shallow breaths)

76
Q

What happens if you accidentally give a barbiturate through an A-line? How do you treat this?

A

Intense vasoconstriction
-excruciating pain radiating along that artery
-obscure distal radial pulses
-blanching of the extremity
-cyanosis
-gangrene
-permanent nerve damage

Tx: Vasodilators –> Lidocaine or Papaverine
-sustain blood flow –> fluids

77
Q

Volatile agents ______ sensory output

78
Q

When ___________ monitoring is required, barbiturates are the desired drug.

A

SSEP (somatosensory evoked potential) monitoring

79
Q

How long is enzyme induction with continuous infusion of barbiturates?

A

2 - 7 days

not w/ 1 time induction agents, but w/ continuous infusions

80
Q

What drugs do barbiturates accelerate metabolism of? How long does this last? What considerations should I have??

A

Anticoagulants
-phenytoin
-TCAs
-digoxin
-corticosteroids
-bile salts
-vitamin k

This can last for up to 30 days

-May need low molecular wt heparin q12h dt decreased effectiveness of anticoagulants
-increase risk of seizure dt increase metabolism of anticonvulsants

81
Q

How does barbiturates affect the kidneys? What consideration should I have?

A

Moderate/ transient decrease in RBF & GRF dt transient hypotension

considerations: make sure pt is normotensive
-Crystalloids: 10 - 30 mg/kg

82
Q

What is the MOA of Propofol?

A

mediates GABA on GABA-A receptor

83
Q

What is the dose for propofol?

A

Induction: 1.5 - 2.5 mg/kg IV

Conscious sedation (MAC): 25 - 100 ug/kg/min

Maintenance: 100 - 300 ug/kg/min

84
Q

Propofol has a _____ injection time of _____ & produceses unconsciousness within _________

A

rapid

<15 seconds

30 seconds

85
Q

Propofol has ______ CNS effects

86
Q

What is the concentration of 1% propofol? 2%?

A

1%: 10mg/1ml

2%: 20mg/1ml

87
Q

What is the propofol composed of? What is the relevance of these ingredients?

A

10% soybean oil: lipid component; aids in emulsification/mixing of drug evenly

2.25% glycerol: emulsication agent; makes closer to isotonic; decreases pain upon injection

1.2% purified egg phosphatide: emulsifier/stabilization agent

88
Q

what specific allergy is contra with propofol?

A

Egg yolk

If egg or egg white allergy –> not anaphylaxis reaction –> will give trial dose

89
Q

What component of propofol causes the pain upon injection?

A

Soybean oil

90
Q

What are the differences in the commercial brands of propofol?

A

Diprivan: most common

Ampofol: low emulsion
No preservative
Higher pain on injection

Aquavan: Prodrug
Less pain on injection but pain in genital area (dysesthia)
slower onset
larger Vd
higher potency

Cyclodextrins: still in clinical trials
claims no pain upon injection but does

91
Q

Whch version of propofol has the highest potency?

92
Q

Along with GABA-A receptor, proprofol potentiates activity at _______ receptors which contributes to what effect?

A

glycine-R

hypnosis effect

93
Q

T/F: propofol induced immobility is caused by spinal cord depression

A

F

mainly works in brain

94
Q

Propofol is cleared in the ______ 1st and then in the ______ 2nd

A

Lung

Liver

95
Q

What are the active metabolites of propofol? Which is the main one?

A

Glucuronic acid
Sulfate

96
Q

What are the characteristics of propofol? halftime; Vd; clearance; BP; trend; HR trend; context sensitive

A

halftime: 0.5 - 1.5 h
Vd: 3.5-4.5 L/kg
Clearance: 30 - 60 ml/kg/mins
BP: decrease
HR: decrease
context sensitive: 40 mins (based on 8 hr infusion)

97
Q

What are the characteristics of Etomidate? halftime; Vd; clearance; BP; trend; HR trend

A

halftime: 2 - 5 h
Vd: 2.2-4.5 L/kg
Clearance: 10 - 20 ml/kg/mins
BP: No change
HR: No change

98
Q

What are the characteristics of Ketamine? halftime; Vd; clearance; BP; trend; HR trend

A

halftime: 2 - 3 h
Vd: 2.5 - 3.5 L/kg
Clearance: 16 - 18 ml/kg/mins
BP: Increase
HR: Increase

99
Q

Propofol is metabolized by _________ after leaving VPG

A

plasma esterases

100
Q

T/F: Propofol has no influence on people with renal dysfuntion and cirrhosis

101
Q

What are the doses for propofol? induction; MAC; sub hypnotic; anticonvulsant; antipruritic

A

Induction: 1.5 - 2.5 mg/kg IV
MAC: 25 - 100 ug/kg/min
Subhypnotic: 10 - 15 mg IV –> 10 ug/kg/min
Anticonvulsant: 1mg/kg
Antipruritic: 10 mg IV

Peds: require higher doses dt larger central volume and clearance rate from high HR/metabolism)

Elderly: decrease dose (25-50%)

102
Q

What should the plasma levels of propofol be?

A

Unconscious to induction: 2-6 ug/ml

Awake: 1-1.5 ug/ml

103
Q

What is the DOC for brief endoscopy procedures?

104
Q

Propofol has minimal __________ and ______ effects? What do we need to add on?

A

analgesic & amnestic

Versed = amnestic
pain med

105
Q

Propofol is more effective than ______ as an antiemetic. What is its MOA?

A

Zofran

depresses subcortical pathways
direct depressant effect on vomiting center

106
Q

The other benefits of propofol is that it is a potentent ____________, has ________ effects at low doses, and acts as a ________dilator

A

potent antioxidant

analgesia

bronchodilator

107
Q

What are the major CNS effects of propofol?

A

Decreases: CMRO2, CBR, ICP, CPP
-Autoregulation rt CBF/PaCO2 are maintained
-EEG changed similar to thiopental
-No SSEP suppression (unless volatiles or nitrous added)
-Myoclonus during induction/emergence

108
Q

Why is propofol a great drug for neuro?

A

No SSEP suppression (unless volatiles or nitrous added)

109
Q

What are the waves of the EEG? What does each one mean? Which EEG wave do we want for Sx anesthesia?

A

Alpha: awake
Beta: concentrating
Delta: Deep sleep
Gamma: testing
Theta: light sleep

We want Delta waves

110
Q

What are the major CV SE of propofol?

A

Decreased SBP more than thiopental
-inhibit SNS –> decreased SVR
-decrease intracellular Ca dt laryngoscopy stimulus (goes back up)
-low BP exagerated in: hypovolemia, elderly, LV compromise

Bradycardia
-inhibit SNS
-depressed baroreceptors –> No compensatory increase in HR for drop in BP
-Can lead to asystole in healthy adults

111
Q

What should we give with propofol to help balance the bradycardia? Why?

A

Atropine
Glycopyrrolate

Counteracts the decreased vagal tone response, which is profound in pediatrics.

112
Q

What are the pulmonary SE of propofol?

A

Dose dependent depression of ventilation
-synergestic effects w opioids
-intact hypoxic pulm vasconstriction response

113
Q

What are the hepatic & renal SE of propofol?

A

Liver transaminase enzymes or creatinine concentrations are normal

Prolonged infusions:
–Hepatocellula injury
–Propofol infusion syndrome
–Green urine
–Cloudy urine

114
Q

What is the green urine in propofol from? How does this alter renal function?

A

Phenols

There is no alteration in renal function

115
Q

What is the cloudy urine in propofol from? How does this alter renal function? How do you Tx it?

A

uric acid crystallization

no alteration in renal function

increase amount of fluids/crystalloids given

116
Q

Propofol _______ IOP. What considerations should I have?

A

Decreases

Good for Sx in trendelenberg

117
Q

Propofol __________ platelet aggregation

118
Q

What is propofol infusion syndrome?

A

Lactic acid induced by high doses of propofol
infusion > 75 ug/kg/min longer than 24h

S/S: severe/refractory/fatal bradycardia in peds
-rhabdo
Late: cardiogenic shock

Dx: ABG
serum lactate

Tx: ECMO

Anesthesia Pharmacology (6 decks)

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