Induction of anesthesia for the cardiac patient

Question 1

Basic preparation for induction for a cardiac case

Answer 1

one inotrope, one vasopressor, one vasodilator (all preprogrammed), similar syringes for bolus administration plus adrenergic blocker, additional antiarrhythmic medications, anticoagulants/reversal agents

Question 2

FYI

Answer 2

Starts with heaviest medication on the left (and pointing up) and all the way to the right would have nitro (pointing down). He never draws up heparin or protamine until it’s asked for

Question 3

Chronic cardiac medications should be __________ preoperatively with rare exceptions

Answer 3

administered

Question 4

Premedication topic - Anxiolytics should be on-call or in given in holding area if __________

Answer 4

compensated

Question 5

Premedications and their ranges

Answer 5

Midazolam 1-5mg IV, Fentanyl 50-100 mcg IV, Morphine 3-10mg IM, Lorazepam 2-4mg PO

Question 6

Would you most likely hold a long-acting anti-hypertensive?

Answer 6

YES

Question 7

Would you hold imdur, amio, cardizem or a beta-blocker?

Answer 7

NO

Question 8

Preinduction period Review

Answer 8

supplemental oxygen, ECG, SPo2, NIBP, invasive monitors, last minute checks to include SOAP, Blood, Surgeon, Reassess overall cardiopulmonary status

Question 9

You would put cerebral ox on when?

Answer 9

When they first arrive in the room and while they’re on room air to have baseline reading

Question 10

Does Cerebral ox give you a right and left reading?

Answer 10

yes

Question 11

In the 1970s they used high-dose opiod induction techniques but it lost favor in the 1990s secondary to long postoperative ______ _____

Answer 11

intubation times

Question 12

Fentanyl

Answer 12

3-10 mcg/kg, 98% redistributed from the plasma in first hour, LARGE Vd

Question 13

Sufentanil

Answer 13

0.1-1 mcg/kg, 7-10 times more potent than fentanyl, higher pKa and only 20% ionized, half as lipid soluble, LOWER Vd, FASTER recovery time

Question 14

What does of sufentanil did he say he would give?

Answer 14

0.3 mcg/kg

Question 15

Remifentail

Answer 15

0.5 mcg/kg, onset time 1 min and recovery time 9-20 min, widespread extrahepatic hydrolysis by nonspecific tissue and blood esterases, requires careful provision of postoperative pain

Question 16

Propofol dose

Answer 16

1-2 mg/kg

Question 17

Propofol is capable to drop what four things?

Answer 17

SVR, MAP, CI and SV

Question 18

Propfol has extensive __________ allowing rapid ________

Answer 18

redistribution / recovery

Question 19

Propofol whould be used with caution or reserved for hemodynamically stable cardiac patients with good ______ function

Answer 19

ventricular

Question 20

Etomidate dose

Answer 20

0.2 mg/kg

Question 21

Etomidate prodcues a small decrease in _______ and ______ and an INCREASE in _____ and ______

Answer 21

MAP and SVR / HR and CO

Question 22

Etomidate may initiate _________. There can also be an increase in incidence of _________ activity in patientts with know _______ disorders

Answer 22

myoclonus / epileptimform / seizure

Question 23

Etomidate can induce __________ suppression, but this phenomenom is unusual

Answer 23

adrenal

Question 24

Thiopental dose

Answer 24

2-4 mg/kg

Question 25

Thiopental has a _____ onset and can be used safely in hemodynamically stable patients

Answer 25

rapid

Question 26

Thiopental has a ______ redistribution

Answer 26

rapid

Question 27

Cardiovascular effects of Thiopental

Answer 27

dereases preload, myocardial depressant, increases HR via the baroreceptor reflex

Question 28

Is ketamine good for trauma patients?

Answer 28

yes, he will use ketamine, versed, succ in some trauma patients

Question 29

Ketamine dose

Answer 29

2-4 mg/kg

Question 30

Ketamine causes a unique cataleptic trance known as ________ _______

Answer 30

dissociative amnesia

Question 31

Ketamine produces unconsciousness in ___ to ___ sec

Answer 31

20 to 60

Question 32

Ketamine increases ____, _____ and plasma _____ levels

Answer 32

HR, MAP, epi

Question 33

When giving ketamine, are plasma epi levels dependent on an intact sympathetic reserve and robust myocardium?

Answer 33

YES

Question 34

Ketamine is advantageous in what 3 situations?

Answer 34

hypovolemia, major hemorrhage, cardiac tamponade

Question 35

Ketamine cautions

Answer 35

increases ICP and coronary demand from sympathetic stimulation

Question 36

Would you want to use ketamine on someone with left main disease or a closed head injury with a blown pupil?

Answer 36

No

Question 37

Inhalational agents cause modest levels of ________ depression

Answer 37

myocardial

Question 38

Predominant effect of inhalation agents is dose dependent VASODILATION which reduces ____ and _____

Answer 38

BP and SVR

Question 39

Inhalation agents also cause a dose dependent _____ tachycardia

Answer 39

reflex

Question 40

Desflurane should be avoided in those that have ______ and / or _______

Answer 40

asthma / smoke

Question 41

Desflurane is _________ in odor, increases _______ and is an _____ irritant

Answer 41

pungent / HR / airway

Question 42

Short acting muscle relaxants

Answer 42

sucinylcholine

Question 43

intermediate acting muscle relaxants

Answer 43

cisatracurium, rocuronium, vecuronium

Question 44

Long-acting muscle relaxants

Answer 44

pancuronium

Question 45

Vagolytic effects of ___________ tend to counter the vagotonia and bradycardia induced by higher doses of ________

Answer 45

pancuronium / opiods

Question 46

Best muscle relaxant for renal failure

Answer 46

cisatracurium

Question 47

Decompensated state drug plan for induction

Answer 47

remifentanil 1mcg/kg, etomidate 0.2 mg/kg and succinylcholine 1.5mg/kg

Question 48

________ release is an important protective mechanism (student presentation)

Answer 48

angiotensin

Question 49

To protect the kidneys have to maintain adequate ______ and ________

Answer 49

volume and pressure

Question 50

Renal failure usually presents on POD# ___

Answer 50

3