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Pharmacology I - CP > Inhalational Agents > Flashcards

Inhalational Agents Flashcards

1
Q

What is added on modern anesthetic agents?

A

diethyl group

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2
Q

the 3 A’s of inhalational general anesthesia

A

amnesia, analgesia, areflexia

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3
Q

Action of general anesthesia agents

A

altered transmission in the cerebral cortex

additional effects on: brain stem arousal center, central thalamus, spinal cord

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4
Q

What makes them cross blood brain barrier quickly?

A

carbon based

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5
Q

Stage 1 of Anesthesia

A

Amnesia and Anesthesia

initiation of anesthesia: LOC, follow simple commands, protective reflexes, eyelid reflex intact

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6
Q

Stage 2 of Anesthesia

A

Delirium and Excitation
LOC and eyelid reflex, irregular breathing, dilated pupils, extremely hypersensitive - vomiting, laryngospasm, cardiac arrest, emergence delirium, avoid manipulating!

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7
Q

Stage 3 of Anesthesia

A

Surgical Anesthesia - where we want them!
cessation of spontaneous respiration, absence of eyelash response and swallowing reflex

should get benefit of 3 A’s here

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8
Q

Who do we see stage 2 exaggerated in?

A

young kids

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9
Q

Stage 4 of Anesthesia

A

anesthetic overdose!

cardiovascular collapse

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10
Q

Are we hyperdynamic or hypodynamic in stage 2?

A

hyperdynamic (elevated BP and HR)

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11
Q

choice of anesthesia based on

A

proposed surgery
comorbidities
provider experience
surgeon

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12
Q

When was nitrous oxide discovered and by who?

A

1793 by Joseph Priestley

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13
Q

When was nitrous oxide successfully used in a dental procedure and by who?

A

1842 by Horace Wells

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14
Q

when was diethyl ether first used in medicine and by who?

A

1842 by Crawford Long

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15
Q

What day is ether day and why is it that day?

A

October 16.. on this day in 1846 William TG Morton removed a tumor from a jaw using diethyl ether

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16
Q

When was chloroform discovered and by who?

A

1831 by Dr. Samuel Guthrie

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17
Q

When was chloroform first used as an anesthetic and by who?

A

1847 by Sir James Young Simpson

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18
Q

What is unique about chloroform?

A

nonflammable, highly potent

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19
Q

When did Dr. John Snow use chloroform?

A

in 1853 on Queen Victoria during child birth

but had developed the first vaporizer

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20
Q

When was Halothane developed?

A

1956

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21
Q

Significance of Halothane?

A

first halogenated anesthetic agent, non flammable, metabolized in liver, causes hepatoxicity

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22
Q

How does an inhalation agent work?

A

it starts in liquid form, gets vaporized, and breathed in and delivered to the brain

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23
Q

absorption of inhalational agents are related to

A

ventilation, blood uptake, cardiac output, blood solubility, and alveolar to blood partial pressure difference

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24
Q

the concentration or partial pressure of gas in the lungs is assumed to be ____

A

be equal in the brain

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25
Q

Definition of MAC

A

minimum alveolar concentration (%) required to produce anesthesia (lack of movement) in 50% of population

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26
Q

the faster the lung concentration rises

A

the faster anesthesia is achieved

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27
Q

Increase MAC if

A

hyperthermia, increase in CNS activity, hypernatremia, chronic alcohol abuse

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28
Q

Decrease MAC if

A

hypothermia, increased age, alpha 2 agonists (dex), acute alcohol ingestion, pregnancy, hyponatremia

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29
Q

rubber and plastic pieces and CO2 absorbent can ___

A

retain gas delaying initial uptake

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30
Q

all inhalational agents except ____ can trigger ___

A

nitrous oxide ; malignant hyperthermia

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31
Q

ways to avoid triggering malignant hyperthermia in at risk patient

A

flush 10mL/min for 20 minutes, replace all breathing circuits and CO2 absorbent, remove all vaporizers, charcoal filters

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32
Q

increasing liter flow during induction ____ agent intake

A

accelerates

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33
Q

Definition of Blood:Gas Solubility

A

describes amount of gas that will dissolve or bind to blood vs the amount that will diffuse into tissues

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34
Q

isoflurane solubility coefficient

A

1.4

there is 1.4x more gas soluble in the blood than available to the tissues

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35
Q

desflurane solubility coefficient

A

0.42

only .42 stays in blood for every molecule that is available to the tissues (put to sleep quicker and awake faster)

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36
Q

Which is more potent isoflurane or desflurane?

A

isoflurane

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37
Q

Over-pressuring or Concentration Effect

A

administration of higher concentration of gas than necessary to speed up initial uptake

greater effect on high solubility gases

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38
Q

Second gas effect

A

co-administering a 2nd agent with NO to speed the onset of the slower agent

also used in emergence to quickly remove slower gas

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39
Q

Why don’t we use nitrous oxide with Desflurane often?

A

can cause tachycardia/arrhythmia if over-pressurized, toxic to environment

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40
Q

oil:gas solubility

A

ability to get into tissues, indicator of potency

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41
Q

higher lipid soluble drugs tend to be ___

A

more potent

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42
Q

the circulatory system has 2 major influences on anesthetic gases

A
  1. uptake

2. distribution

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43
Q

an increase in cardiac output

A

slows uptake

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44
Q

approximately 5-8% of sevoflurane is metabolized

A

by the liver

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45
Q

decreases in temperature results in

A

increased potency and solubility

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46
Q

hypothermia decreases

A

tissue perfusion = slowed induction

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47
Q

how can decreased tissue perfusion in hypothermia be overcome?

A

increase gas concentration, warm the patient if able

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48
Q

hypothermia increases

A

tissue anesthetic capacity (slow recovery)

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49
Q

hyperthermia increases

A

cardiac output and anesthetic requirement (slows induction)

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50
Q

a patient receiving nitrous oxide during a case should receive

A

100% oxygen on emergence

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51
Q

the longer an anesthetic gas is used during the case

A

the slower the emergence

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52
Q

the higher the solubility

A

the slower the emergence

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53
Q

emergence phase 1

A

cessation of anesthetic, reversal, apnea to breathing, increased alpha and beta waves on EEG

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54
Q

emergence phase 2

A

increased HR and BP, return of autonomic responses, responsiveness to pain, salivation, tearing, grimacing, swallowing and gagging, defensive posturing

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55
Q

emergence phase 3

A

eye opening, response to verbal commands, awake EEG, extubation possible

56
Q

nitrous oxide is ___ soluble than nitrogen

A

34 times more

57
Q

when nitrous oxide is being administered what can happen

A

increased volume in air containing cavities (abdominal distension)

58
Q

anesthetic agents are ___ soluble and ___ uptake in kids over adults

A

less; greater

59
Q

right to left shunt

A

ex. PE

shunted blood mixes and dilutes blood reducing anesthetic partial pressure and slows induction

60
Q

left to right shunt

A

ex. septal defect

increases uptake

61
Q

What are all of the modern inhalation agents based off of?

A

ether

62
Q

What is the basic structure of ether?

A

R-O-R

63
Q

What is fresh gas flow determined by?

A

vaporizer and flowmeter settings

64
Q

Fi stands for and is determined by

A

inspired gas concentration, determined by FGF rate, breathing circuit volume, and circuit absorption

65
Q

FA stand for and is determined by

A

alveolar gas concentration, uptake, ventilation, concentration effect and second gas effect

66
Q

Fa stand for and is determined by

A

arterial gas concentration, affected by ventilation/perfusion mismatching

67
Q

What could cause V/Q mismatch in terms of intubation

A

right bronchial intubation, PFO

68
Q

What do inhalational agents most likely target?

A

NMDA receptors, tandem pore potassium channels, VGNaCh, glycine receptors, GABA receptors

69
Q

According to the Meyer Overton theory…

A

lipophilicity equals potency

70
Q

CMRO2 is ____ with inhalational agents

A

decreased

71
Q

Cerebral blood flow is ___ with inhalational agents

A

increased

72
Q

What happens with “uncoupling”

A

CMRO2 decreased, CBF increased except for NO it increases both

73
Q

cerebral vascular responsiveness to CO2 is

A

vasodilate

74
Q

When does Burst suppression occur with inhalational agents?

A

1.5 MAC of desflurane, 2 MAC with isoflurane and sevoflurane

75
Q

In terms of evoked potentials, inhalational agents

A

decrease amplitude (height) and increase latency (how often response is occuring)

76
Q

What is the proposed mechanism of developmental neurotoxicity?

A

activation of extrinsic and intrinsic apoptic cell death pathways

77
Q

What does PANDA stand for in PANDA study

A

pediatric anesthesia neuorodevelopment analysis

78
Q

What does GAS stand for in the GAS trial

A

general anesthesia vs spinal

79
Q

Who should we be concerned about postoperative cognitive dysfunction with?

A

the elderly

80
Q

who should we be concerned with emergence delirium with?

A

children

81
Q

what inhalational agents is more common with emergence delirium?

A

sevoflurane and desflurane (insoluble, get in quick, get out quick)

82
Q

all volatile inhalational agents ___ CO

A

reduce

83
Q

as MAC hours increase, ____ CI and HR

A

slight increase

84
Q

reduced MAP secondary to

A

SVR reduction

85
Q

how do inhalational agents induce HR changes?

A

via SA node antagonism, modulation of baroreflex activity, SNS activity (blunting)

86
Q

all inhalational agents produce

A

vasodilation (SVR)

87
Q

in hypotensive patients vasodilation can result in

A

reverse Robinhood syndrome (steal from poor give to the rich)

88
Q

which inhalational agent is most associated with reverse robinhood syndrome?

A

isoflurane

89
Q

preconditioning

A

the heart is exposed to intracellular events that protect it from ischemic and reperfusion insult

90
Q

sensitization

A

volatile agents reduce the quanity (desensitize) of catecholamines necessary to evoke arrhythmias

91
Q

safe epi dosing

A

10mL of 1:100,000 (10mcg/mL) in a 10 minute period or up to 30 mL in one hour

92
Q

nitrous oxide causes a slight increase in

A

PVR , worsens with patients with pulmonary HTN

93
Q

volatile agents decrease

A

pulmonary artery pressure

94
Q

hypoxic pulmonary vasoconstriction is

A

depressed

95
Q

which drug has the greatest effect on HPV?

A

isoflurane

96
Q

volatile agents cause decreases in

A

tidal volume and responsiveness to CO2

97
Q

how is decreased tidal volume compensated for?

A

increased RR (not sufficient to offset TV)

98
Q

which causes the least bronchodilation?

A

desflurane

99
Q

which has least impact of renal function?

A

desflurane

100
Q

use of older absorbents can increase likelihood

A

nephrotoxicity with sevoflurane

101
Q

should not exceed 2 MAC hours at flows ___

A

<2L per minute

102
Q

Halothane has what affect on hepatic function?

A

is associated with Halothane Hepatitis

103
Q

what causes halothane hepatitis?

A

metabolites binding to proteins and forming antibodies, re-exposure to Halothane antibodies mediate massive hepatic necrosis

104
Q

Advantage of fluorination

A

resists hepatic degradation

105
Q

which drug undergoes the most metabolism?

A

sevoflurane (5-8%)

106
Q

is sevoflurane toxic to liver?

A

no, can be toxic to kidneys though d/t fluoride ions

107
Q

volatile agents have additive effect with

A

nondepolarizing NMBDs

108
Q

an ideal anesthetic agent

A 
nonirritating to respiratory tract
rapid induction and emergence
chemically stable (nonflammable)
produce amnesia, analgesia, areflexia
potent
not metabolized and excreted by respiratory tract
free of toxicity and allergic reactions
minimal systemic changes
uses a standardized vaporizer
affordable
109
Q

what four properties affect how agents work

A

vapor pressure, boiling point, partial pressure, solubility

110
Q

what is vapor pressure

A

pressure exerted inside a container between liquid and vapor

111
Q

as long as liquid is present, vapor pressure is

A

independent of volume

112
Q

vapor pressure is directly proportional to

A

temperature

113
Q

boiling point

A

temperature at which vapor pressure exceeds atmospheric pressure in an open container

114
Q

partial pressure

A

fraction of pressure within a mixture (Dalton’s Law)

115
Q

solubility

A

tendency of a gas to equilibrate with a solution (Henry’s Law)

116
Q

the concentration of anesthetic in tissue is dependent on

A

the partial pressure and solubility

117
Q

what is used instead of partial pressure

A

inspired concentration or fractional volumes

118
Q

for most drugs, concentration is measured as

A

mass (mg/mL) but can be expressed in percent by weight or volume

119
Q

MAC awake

A

MAC in which 50% opens eyes to command

120
Q

MAC bar

A

the MAC necessary to block adrenergic response to stimulation

121
Q

MAC ___ with age

A

decreases

122
Q

How much should MAC decline with age?

A

6% each decade after age 40

6% of 6% for example

123
Q

how do vaporizers facilitate movement of anesthetic from machine to patient

A

by fresh gas flow, pressure, and temperature

124
Q

isoflurane (general facts)

A 
halogenated methyl ethyl ether
most potent, most soluble
slow onset and recovery
dilates coronary arteries - reverse robinhood
minimal cardiac depression
pungent, not used for induction
125
Q

desflurane (general facts)

A

least potent
quicker induction and emergence
heated and pressurized to maintain constant
can boil at room temp
rapid increase in gas can increase HR and BP
very pungent
avoid in pts with reactive airway disease
bad for the environment

126
Q

sevoflurane (general facts)

A 
fluorinated methyl isopropyl ether
moderate potency
rapid induction and emergence
may prolong QT interval
nonpungent
preferred agent for induction
small percent metabolized by CYP
soda lime can degrade into Compound A (nephrotoxic)
127
Q

safety factors for sevoflurane

A

calcium hydroxide absorbent, flows 2lpm, avoid in renal dysfunction

128
Q

nitrous oxide (general facts)

A 
not volatile, colorless and odorless
gas at room temp
nonflammable
NMDA receptor antagonist
have to weigh it
stimulates SNS, increases RR, decreases hypoxic drive
increases CMRO2 and CBF 
increases risk of PONV
129
Q

absolute and relative contraindications for NO

A

absolute: methionine synthase pathway deficiency, expansion of gas filled space
relative: PONV, 1st trimester pregnancy, increased ICP, pulmonary HTN, prolonged surgery

130
Q

Xenon (general facts)

A

noble gas, odorless, colorless, naturally occuring, acts on NMDA and glycine receptors, minimal effects
rare and hard to get
ideal agent

131
Q

malignant hyperthemia triggered by

A

succinylcholine and volatile anesthetics

stress

132
Q

malignant hyperthermia receptor

A

ryanodine receptor gene mutation (chromosome 19)

133
Q

S/S of malignant hyperthemia

A

incease in CO2 production, muscle rigidity, metabolic acidosis, high temp, urine color darkens, tachycardia, tachypnea

134
Q

treatment of malignant hyperthermia

A

dantrolene sodium or ryanodex**

135
Q

dose of dantrolene sodium (w/ mannitol and sodium hydroxide)

A

1 mg/kg
*70mL vials containing 20mg
administer until side effects subside or up to 10mg/kg
takes forever to mix!!

136
Q

ryanodex

A

requires fewer vials and less reconstituion, shorter half life, requires supplementation of mannitol

Pharmacology I - CP (8 decks)

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