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NUNA 681 Pharm II > Inhalational agents - effects on MSK, neuro, hepatic, renal, and metabolism > Flashcards

Inhalational agents - effects on MSK, neuro, hepatic, renal, and metabolism Flashcards

1
Q

inhaled volatile agents cause a dose dependent _______ ______ _______

A

relaxation of skeletal muscle

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2
Q

but ______ has no effect on skeletal muscle relaxation

A

N2O

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3
Q

the higher the MAC multiple, the greater the _____ ____ ______

A

fade on tetanus

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4
Q

inhaled anesthetics can be used instead of ________ or to enhance the effect of ______

A

NMB
NMB

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5
Q

this enhanced effect of NMB may be from _____ or _____-______ effects or from effects on the spinal ______ _____

A

pre or post-synaptic
motor neurons

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6
Q

agents inhibit ______ receptors incompletely at MAC

A

nicotinic

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7
Q

practical application of inhaled anesthetics (4)

A
  1. decreases doses of nondep NMB 25% (50%)
  2. decreases frequency of redosing
  3. myasthenia gravis patient - give NO NMB
  4. patient with hepatic or renal impairment
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8
Q

Roc has a ______ duration depending on the volatile agent interaction:
Des ___ mins
Sevo ___ mins
Iso ___ mins
Prop ___ mins

A

longer
Des 90 mins
Sevo 59 mins
Iso 35 mins
Prop 35 mins

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9
Q

Roc duration explains the prolonged ______ from ______ when volatile concentration is maintained

A

recovery from NMB

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10
Q

One study examined the effect of decreasing the concentration of volatile on the twitch height when a vecuronium infusion was maintained. As the % concentration decreased, the twitch height ______, although the vecuronium infusion was ________.

A

increased
unchanged

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11
Q

Eger demonstrated the “substitution” of ___ ________ for NMB with an abdominal surgery in which muscular relaxation was desired by the surgeon

A

9% Desflurane

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12
Q

Effects on neuromuscular system: _______ results with ______ agents

A

different
different

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13
Q

Effects on neuromuscular system: may be explained by ______ of _____

A

methodology of study

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14
Q

Effects on neuromuscular system: with cisat and roc, _______ caused a prolonged block, and ______ didn’t

A

sevo
iso

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15
Q

Effects on neuromuscular system: with vecuronium, _____ and _____ both prolonged block

A

sevo and iso

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16
Q

Effects on neuromuscular system: all volatile agents have an ______ effect with ______

A

additive effect with succinylcholine

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17
Q

Effects on neuromuscular system: iso causes more rapid shift from ______ to ________ block with succ infusion

A

phase 1 to phase 2

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18
Q

Effects on neuromuscular system: TIME-dependent enhancement of _________

A

non-depolarizing NMB (recovery of ToF 1 twitch)

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19
Q

Effects on neuromuscular system: sevo 30 mins delayed recovery from vec ____

A

89%

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20
Q

Effects on neuromuscular system: sevo 60 mins delayed recovery from vec _____

A

100%

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21
Q

Effects on neuromuscular system: volatile agents can cause impairment of ______ of ________ NMB

A

reversal
non-depolarizing

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22
Q

Effects on neuromuscular system: take home message

A

CAREFULLY administer NMB, use your twitch monitor, and consider using relaxant effect of volatile in lieu of NMB, if possible

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23
Q

Uterine smooth muscle: volatile anesthetics cause dose-dependent ________ of the uterine smooth muscle

A

relaxation

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24
Q

Uterine smooth muscle: ___ ____ - modest relaxation

A

0.5 MAC

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25
Q

Uterine smooth muscle: ____ ____ - significant relaxation

A

greater than 1 MAC

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26
Q

Uterine smooth muscle: positive implication - desirable relaxation for ______ of ______ ______

A

removal of retained placenta

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27
Q

Uterine smooth muscle: negative implication - contribute to increased _____ ______ with uterine ______

A

blood loss
uterine atony

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28
Q

Uterine smooth muscle: _____ does not alter uterine contractility in doses used to provide analgesia during vaginal delivery

A

N2O

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29
Q

Uterine smooth muscle: N2O can be useful to ______ volatile and ______ benzodiazepines/opioids

A

decrease
avoid

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30
Q

Effect on uterine blood flow: ______ in maternal blood flow

A

decreases

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31
Q

Effect on uterine blood flow: decreases in uterine blood flow
- maintain ____ _____
- evidence of _____ ______ not present

A

< 1.5 MAC
fetal distress

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32
Q

Effect on uterine blood flow: ______ with no neonatal distress

A

amnesia

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33
Q

Effect on uterine blood flow: amnesia with no neonatal distress
- ____ MAC with ____ ____
- consider avoiding _____ in fetal distress

A
  • 0.5 MAC with 50% N2O (total equivalent of 1 MAC)
  • consider avoiding N2O in fetal distress
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34
Q

Malignant Hyperthermia: ____ ____ agents can trigger MH (even without ______)

A

all volatile
succinylcholine

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35
Q

Malignant Hyperthermia: _______ is the most potent trigger

A

halothane

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36
Q

Malignant Hyperthermia: ______ is a much weaker trigger and is on the MHAUS safe list

A

N2O

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37
Q

Malignant Hyperthermia: is a pathologic change in _____, ________ state

A

muscle
hypermetabolic

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38
Q

Malignant Hyperthermia: exposure to triggering agents cause the ______ ______ to release calcium from the ______ _____ to enter the muscle cell

A

ryanodine receptor
sarcoplasmic reticulum

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39
Q

Malignant Hyperthermia: muscle contraction occurs due to interaction of _____ and _____

A

actin and myosin

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40
Q

Malignant Hyperthermia: both aerobic and anaerobic muscle metabolism increase producing massive amounts of _____, _____, and ______

A

heat, CO2, and lactate

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41
Q

Malignant Hyperthermia: muscle membrane permeability allows ______

A

leakage

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42
Q

Malignant Hyperthermia: time to onset with volatile agent trigger only
- Des ____ minutes
- Iso _____ minutes
- Halo ____ minutes

A
  • Des 260 mins (pt could even be home at this time)
  • Iso 140 mins
  • Halothane 35 minutes
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43
Q

CNS: CMRO2 requirements decrease at approx. ______ as the patient moves towards unconsciousness

A

0.4 MAC

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44
Q

CNS: reduction in CMRO2 is _____ ______

A

dose dependent

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45
Q

CNS: once an ______ _____ is produced, further increases in the agent concentration do not further decrease CMRO2

A

isoelectric EEG

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46
Q

CNS:
- CMRO2 - ______ ______ 60% + _____ _____ 40%

A

electrical activity
cellular homeostasis

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47
Q

CNS:
CMRO2 decreases normal response with no volatile anesthesia: brain _____ (____) its blood flow with its ______ ______

A

matches (couples)
metabolic requirements

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48
Q

CNS:
CMRO2 decreases when ______ _____ decrease, blood vessels _______, and _____ decreases

A

metabolic demands
constrict (CVR increases)
CBF

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49
Q

CNS:
2 opposing factors with volatile anesthetics
- vasoconstriction from _______ of _____
- vasodilation from _______ _____ _____

A
  • reduction of CMRO2
  • anesthetic agent directly
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50
Q

CNS: no uncoupling if ______ of des or iso

A

less than or equal to 1 MAC

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51
Q

CNS: ________ can occur at higher doses

A

uncoupling

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52
Q

CNS: N2O causes increased ______ and _____.

A

CMRO2 and CBF

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53
Q

CNS: However, with N2O there is still _______ due to the greater increase in ______ than ______

A

uncoupling
CMRO2
CBF

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54
Q

CBF: may ______, remain _______, or _______ - different studies

A

increase
unchanged
decrease

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55
Q

What affects change in CBF? (5)

A
  1. dose of volatile
  2. other drugs administered (prop, opioids, barbiturates, nitrous)
  3. rate of change of concentration of volatile
  4. ventilation (hyper- )
  5. animal used in study

she alluded that this was a test question

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56
Q

CBF: volatiles cause dose-dependent ______ in CBF

A

increase

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57
Q

CBF: normocarbia, > 0.6 MAC causes (4 things)

A
  1. cerebral vasodilation
  2. decreased CVR
  3. increased CBF (potential increased ICP)
  4. OBTW: decreased CMRO2 (coupling should result in decreased CBF)
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58
Q

cerebral vasodilation: ____ = ____ > ____

A

iso = des > sevo

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59
Q

increase in CBF occurs _____ _____ of administration of inhaled agent

A

within minutes

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60
Q

increased CBF is independent of _____ and can be sustained for as long as ___ ____ during an anesthetic

A

MAP
4 hours

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61
Q

greater decrease in CMRO2 by ______ may explain why CBF is not significantly increased at ____ _____

A

isoflurane
< 1 MAC

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62
Q

lower metabolism = ____ _____ production, _____ ____dilation

A

less CO2
less vasodilation

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63
Q

CNS: ______, ______, & _______ maintain the cerebral vascular reactivity to CO2 at less than __ MAC

A

desflurane, sevoflurane, and isoflurane
< 1 MAC

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64
Q

CNS: Iso, Des, and Sevo at ___ ____ preserve autoregulation of _____

A

1 MAC
CBF

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65
Q

CNS: Halothane _____ ______

A

eliminates autoregulation

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66
Q

CNS: at 1.5 MAC _____ preserves autoregulation better than ____

A

sevo
iso

67
Q

CNS: as dose increases above 1 MAC, _______ is affected (CBF is more dependent on _____)

A

autoregulation
MAP

68
Q

CBF is maintained (unchanged or higher). CMRO2 is _____. (iso>halothane) = _______ at ______ doses

A

decreased
uncoupling at higher doses (> 1 MAC)

69
Q

CNS: _____ may blunt necrotic processes resulting from ______ ischemia due to transient _____ ischemia during ______ ______

A

isoflurane
cerebral
regional
carotid endarterectomy

70
Q

CNS: bc isoflurane may blunt necrotic processes, cerebral _____ _____-_____ ______ is improved

A

oxygen supply-demand balance

71
Q

cerebral vasodilation and increased CBF raise risks of ______ _____

A

increased ICP

72
Q

CNS: hyperventilation to decrease the _____ to ____ mmHg counters the increased ICP

A

PaCO2 to 30 mmHg

73
Q

CNS: iso, sevo, des - start hyperventilation with _____ ___ _____

A

start of agent

74
Q

CNS: halothane - start hyperventilation ______ _______ _____

A

before agent is started

75
Q

CNS: iso does not change production of ____, but decreases resistance to ________

A

CSF
reabsorption (increases reabsorption)

76
Q

CNS: the result of iso increasing CSF reabsorption is only _______ ______ in ______ (even if CBF increases)

A

minimal increases in ICP

77
Q

CNS: des may _____ or not change CSF production

A

increase

78
Q

CNS: sevo ______ CSF production

A

decreases

79
Q

CNS: N2O ___ ____ in CSF production

A

no increase

80
Q

CNS: normal response to hypocarbia and PaCO2 goal

A

vasoconstrict
goal is PaCO2 30-35 mmHg - effective 4-6 hrs

81
Q

CNS: normal response to hypercarbia

A

vasodilate

82
Q

CNS: differences in literature (3)

A
  1. type of surgical procedure
  2. pathophysiology
  3. coexisting diseases
83
Q

EEG effects: less than 0.4 MAC, ______ _____ and _____

A

increased frequency and voltage

84
Q

EEG effects: at 0.4 MAC, activity shifts to ______ portions of the brain, transition from ______ to _______

A

anterior
excitement to unconsciousness

85
Q

EEG effects: typically, ______ voltage and ______ frequency at about 1 MAC

A

increased voltage
decreased frequency (bigger slower waves)

86
Q

EEG effects: the deeper the level of anesthesia, _____ ______ occurs (1.5 MAC) and possibly _____ _____ (2 MAC)

A

burst suppression
flat EEG

87
Q

EEG effects: exception - ________ does not produce burst suppression at clinical levels

A

halothane

88
Q

EEG effects: des, iso, and sevo can suppress ______ activity related to drugs like ______

A

seizure
lidocaine

89
Q

EEG effects: however, _______ has been associated with seizure activity but MOA is uncertain

A

sevoflurane

90
Q

EEG effects: sevo associate with seizures - increased incidence with higher concentrations (__ ____), ____carbia, repeated auditory _____, and pre-existing _____ _____

A

2 MAC
hypocarbia
stimulation
seizure disorder

91
Q

EEG effects: question regarding a possible link between this seizure tendency and increased risk of ______ on emergence with sevo

A

delirium

92
Q

Evoked Potentials is monitoring the transmission of the impulse from the _______ to/through the _____

A

periphery
cord

93
Q

Evoked Potentials are typically utilized with ____ _____ for _____

A

spinal fusions for scoliosis (monitoring to protect the spinal cord)

94
Q

Evoked Potentials: ALL potent inhaled anesthetics depress ______

A

SSEP

95
Q

Evoked Potentials: inhaled anesthetics have a dose-dependent ______ in evoked potentials with _____ _____ being the most sensitive and _______ _____ being the most resistant

A

reduction
visual EP
brainstem EP

96
Q

Evoked Potentials: an increase in _______ or decrease in _______ are indications of ischemia OR can be related to the volatile agent

A

latency (time of stimulus in periphery and onset of EP recorded by scalp electrode)
amplitude

97
Q

Evoked Potentials: clinically at ____ -____ MAC

A

0.5-0.7 MAC

98
Q

Evoked Potentials: research shows sevo and des can be utilized at ____ ____

A

1.3 MAC

99
Q

Evoked Potentials: research shows that isoflurane can be utilized at ____-____ ____

A

0.5-1 MAC

100
Q

Evoked Potentials: research shows halothane can be utilized at ___-___ ____

A

0.5-0.7 MAC

101
Q

Evoked Potentials: _____ may profoundly decrease amplitude of evoked potentials so AVOID

A

N2O

102
Q

Awareness: volatile agents do not cause ____ _____

A

retrograde amnesia

103
Q

Awareness: volatile anesthetics are ____ _____ in the effectiveness of preventing awareness

A

not equal

0.4 MAC iso prevents awareness whereas > 0.5 - 0.6 MAC N2O is required

104
Q

Awareness: ______ may be altered at low concentrations (as low as _____)

A

learning
0.2 MAC

105
Q

Awareness: surgical stimulation may increase the concentration required to _____ ______

A

prevent awareness

106
Q

Temp Regulation: impairment of ______ ______ of temperature control

A

cerebral regulation

107
Q

Temp Regulation: inhaled agents reset the ______ for regulation of temperature control to a _____ level

A

threshold
lower

108
Q

Temp Regulation: _____ has less of an effect; substitution of ______ impairs the threshold less

A

N2O
N2O

109
Q

Temp Regulation: inhaled agents cause center for temp regulation to permit a lower range of temperatures to exist before _______ _______ occurs

A

cutaneous vasoconstriction

110
Q

Temp Regulation: inhaled agents permit a lower temp before the body attempts to regulate ____ ____ and ____ _____

A

heat loss and heat production

It is DOSE-RELATED

111
Q

Temp Regulation: _______ can also lead to temp loss

A

vasodilation

112
Q

Temp Regulation: vasodilation results in heat transferred from _____ to ______ and this causes a decrease in core temp of 0.5-1 degree celsius in the first ____ ____ of anesthesia

A

core
periphery
half hour

113
Q

Temp Regulation: elderly have greater _____ of temp regulation than other

A

inhibition

114
Q

Neuroapoptosis: neurotoxicity in _______

A

animals

115
Q

Neuroapoptosis: no predominant mechanism - altered neurogenesis, _____ growth, and _____ formation contributing to remodeling of ____ _____ and _______ remodeling

A

neurite
synapse
neuronal circuitry
developmental

116
Q

Neuroapoptosis: ______ deficits, delayed _____

A

cognitive
learning

117
Q

Neuroapoptosis: impaired memory ______ and ______

A

formation and retention

118
Q

Neuroapoptosis: altered _____ and _____ development

A

motor and behavioral development

119
Q

Neuroapoptosis: FDA issued a safety announcement advising that repeated or lengthy exposures to anesthetic or sedative drugs prior to age _____ have the potential to harm children’s brains

A

3

120
Q

Hepatic Blood Flow: Iso (___), Des, and Sevo _______ total hepatic blood and artery flow

A

1.5%
maintained

121
Q

Hepatic Blood Flow: iso/des/sevo increased ____ _____ _____ _____

A

increased portal vein blood flow (hepatic vasodilator)

122
Q

Hepatic Blood Flow: halothane is a hepatic ______ ______

A

artery vasoconstrictor

123
Q

% of anesthetic biodegraded: desflurane

A

0-0.02%

124
Q

% of anesthetic biodegraded: isoflurane

A

0-0.2%

125
Q

% of anesthetic biodegraded: sevoflurane

A

5-8%

126
Q

% of anesthetic biodegraded: halothane

A

15-40%

127
Q

% of anesthetic biodegraded: N2O

A

trick question

N2O isnt metabolized in the liver but in the gut by normal flora (0.004%)

128
Q

Determinants of metabolism: chemical structure (2)

A

chemical bond
carbon-halogen bond

129
Q

Determinants of metabolism: hepatic enzyme activity (2)

A

cytochrome p-450 induced or depressed
obese - increased fluoride concentrations

130
Q

Determinants of metabolism: blood concentration - < 0.1 MAC undergoes extensive metabolism in the _____ (less soluble - quicker out via _____)

A

liver
lungs

131
Q

Determinants of metabolism: all inhaled anesthetics are metabolized, just to _____ _____

A

varying degrees

132
Q

Determinants of metabolism: the concern is the ______

A

fluoride

133
Q

Determinants of metabolism: the metabolites of concern are ________ _____ and ______ ______

A

trifluoroacetic acid (TFA)
inorganic fluoride

134
Q

Determinants of metabolism: metabolic pathways are oxidative for ____, _____, _____

A

des, iso, sevo

135
Q

Harmful metabolism: metabolism of halothane - principally ______ by cytochrome p-450 enzymes when ______ is present, but _______ metabolism when hepatocyte PO2 decreases

A

oxidation
oxygen
reductive

136
Q

Harmful metabolism: TFA is produced by biodegradation of ____, ____, and _____. It causes acetylation of proteins on the surface of hepatocytes to form ______ to which ______ form

A

hal, iso, des
antigens
antibodies

137
Q

Harmful metabolism: TFA - connection between its hepatic production and hepatotoxicity via an _____ _____

A

immune pathway

138
Q

Harmful metabolism: TFA - significant difference in percentage of _____ & ____ metabolized vs ______

A

iso & des
halothane

139
Q

Inorganic fluoride - nephrotoxicity: produced by the biodegradation of sevo in the _____ and only minimally in the _____. Thus, little effect on the ______.

A

liver
kidneys
kidneys

140
Q

Inorganic fluoride - nephrotoxicity: same level of inorganic fluoride produced as with ________ which causes renal failure, but no evidence of renal injury, even in patients with existing renal damage

A

methoxyflyrane (50 mcgmol/L)

141
Q

Inorganic fluoride - nephrotoxicity: _______ production of inorganic fluoride (methoxyflurane) is a bigger problem for nephrotoxicity than inorganic fluoride produced from _____ metabolism (sevo)

A

infrarenal
hepatic

142
Q

Inorganic fluoride - nephrotoxicity: historically -
no renal effects @ ______
subclinical toxicity @ _____
clinical toxicity @ _______

A

no renal effects @ < 40 mcm/L
subclinical toxicity @ 50-80 mcm/L
clinical toxicity @ > 80 mcm/L

143
Q

Inorganic fluoride - nephrotoxicity: level of _____ is the indicator that renal toxicity may occur - however, no _____ _____ even with levels exceeding this level.

A

50
renal damage

144
Q

Inorganic fluoride - nephrotoxicity: ____ and _____ are less soluble and exhaled more and less metabolized

A

Enf and Sevo

145
Q

Inorganic fluoride - nephrotoxicity: high out put renal failure is unresponsive to ______, and has an inability to _____ urine, _______, hyper______, hyper______, increased plasma _______

A

vasopressin
concentrate
polyuria
hypernatremia
hyperosmolarity
creatinine

146
Q

Renal effects: studies show no renal _____ after ______

A

necrosis
sevo

147
Q

Renal effects: have been cases of transient impairment of renal ______ ability and increased excretion of ____-____-_______ in patient exposed to sevo and with peak plasma inorganic fluoride levels > ______

A

concentrating ability
beta-N-acetylglucosaminidase (NAG)
50 mcm/L

148
Q

Renal effects: NAG is an indicator of _____ ____ ____ ____ injury

A

acute proximal renal tubular injury

149
Q

Renal effects: no elevation in ______ or _______

A

BUN or creatinine

(not super sensitive indicators)

150
Q

Renal effects: patients with pre-existing renal disease

A

no increased risk for damage

151
Q

Renal effects: renal blood flow is

A

reduced (may effect urine output intraoperatively)

152
Q

Renal effects: decreased _____

A

GFR

153
Q

Renal effects: decreased ____ ____

A

urine output

154
Q

Renal effects: due more to the decrease in ____ and systemic _____. preop ______ attenuates renal effects

A

CO
BP
hydration

155
Q

Renal effects: _____ ____, not inhaled anesthetics, cause release of ADH

A

surgical stress

156
Q

Renal effects: fluid status changes might also cause _____ release to contribute to _____ urine output

A

ADH
decreased

157
Q

Compound A: may cause inability to ____ ____ causing high _____ and decreased response to _____

A

concentrate urine
output
vasopressin

158
Q

Compound A: no ____ ____ has been seen

A

renal necrosis

159
Q

Compound A: however, have seen ______, ______, and _______

A

proteinuria, glucosuria, enzymuria

160
Q

Compound A: to decrease risk, minimum flows of _____ if case longer than _____

A

2L/min
2 hours

161
Q

Compound A: _____ if case is less than 2 hours

A

1L/min

162
Q

Compound A: lower concentrations of ______

A

sevo

163
Q

Compound A: avoid ____ and _____ in CO2 absorbent

A

KOH
NaOH

164
Q

Compound A: avoid increased ______ in CO2 absorbant

A

temperature

NUNA 681 Pharm II (12 decks)

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