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Pharmacology Sem 1 > Inhalational Agents Part 1 > Flashcards

Inhalational Agents Part 1 Flashcards

1
Q

What are the three A’s of anesthesia?

A

Amnesia- loss of memory
Analgesia- loss of sensation and pain control
Areflexia- lack of movement (minimizes sympathetic and parasympathetic changes in vital signs)

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2
Q

What is a benefit to using gas over other agents?

A

Gas has the three properties of amnesia, analgesia, and areflexia versus other drugs would need to be combined to get all of these effects

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3
Q

Gases affect what areas of the body?

A

cerebral cortex, brain stem arousal centers, central thalamus, and spinal cord

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4
Q

Gases crosses

A

the blood brain barrier quickly because it is lipophilic, carbon based, and diffuses quickly

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5
Q

List the stages of anesthesia in order:

A

Stage 1: amnesia and anesthesia
Stage 2: delirium and excitation
Stage 3: surgical anesthesia
Stage 4: anesthetic overdose

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6
Q

What occurs in stage 1 of anesthesia?

A

light plain of anesthesia; initiation of anesthesia to the loss of consciousness; patient able to follow simple commands, protective reflexes remain intact, eyelid reflex intact

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7
Q

What occurs in stage 2 of anesthesia?

A

loss of consciousness and lid reflex, irregular breathing pattern, dilated pupils; neurons that inhibit excitation are not functional and can lead to vomiting, laryngospasm, cardiac arrest, and emergence delirium
Would not want to manipulate anything in this stage due to hyper-reactivity

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8
Q

What occurs in stage 3 of anesthesia?

A

cessation of spontaneous respirations; absence of eyelash response and swallowing reflexes
risk for aspiration because there’s no airway reflexes

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9
Q

What is stage 4 of anesthesia?

A

cardiovascular collapse requiring provider intervention

too much of a good thing

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10
Q

What does the respiratory pattern look like under gas?

A

smaller, more frequent breaths

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11
Q

What patient population tends to be exaggerated for their stages of anesthesia?

A

children

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12
Q

When we discuss the stages of anesthesia, we are typically discussing

A

emergence because we give them induction agents as well so we skip some stages

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13
Q

When we give a combination of agents,

A 
we bypass stages such as stage 2
using sedation (benzodiazepines, alpha 2 agonists) and induction/maintenance (barbiturates, propofol, etomidate, ketamine, TIVA
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14
Q

What drugs are synergistic with gases?

A

analgesics: opioids, non-opioids
Paralytics: non-depolarizing & depolarizing
Adjuncts: regional anesthetics
Would need to give less gas in this situation

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15
Q

Choice of anesthesia is based on:

A

proposed surgery
patient comorbidities
provider experience
surgeon

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16
Q

Perioperative considerations include:

A

preoperative- anesthetic based upon assessment, proposed surgery, patient comorbidities, provider experience, and surgeon
intraoperative- married to our plan, need to have back up plan if surgeon is taking longer
postoperative: responsibility to follow up and make sure anesthesia worked

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17
Q

Absorption of inhalational agents are related to:

A

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

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18
Q

Where do we measure the concentration of inhalational agents?

A

at the lungs because we make the assumption that what’s in the lungs is what’s in the brain

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19
Q

Administration of an inhalation agent involves

A

taking a liquid, vaporizing it, and delivering it to the brain

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20
Q

The main factors in anesthetizing a patient are

A

technical and machine related, drug specific, and patient factors such as respiratory, circulatory and tissue

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21
Q

What is MAC?

A

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

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22
Q

What conditions require increased MAC?

A

hyperthermia, drug-induced increases in CNS activity, hypernatremia, chronic alcohol abuse
assuming that we are using gas only

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23
Q

The dose of gas is expressed as

A

minimal alveolar concentration or MAC

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24
Q

MAC is

A

age dependent; peaks at 6 months and decreases with age

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25
Q

The faster the lung concentration rises

A

the faster anesthesia is achieved

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26
Q

MAC awake means

A

patients are not getting full anesthetic gas

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27
Q

Factors that decrease MAC include

A

hypothermia, increasing age, alpha-2 agonists, acute alcohol ingestion, pregnancy, hyponatremia

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28
Q

What are machine-related factors that impact our gas anesthesia?

A

Rubber and plastic machine pieces and CO2 absorbent can retain gas delaying initial uptake
-can retain small quantities of anesthetic gases so must be flushed

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29
Q

All inhalational agents can trigger

A

malignant hyperthermia (except nitrous oxide); a thorough flush at 10 L/min for 20 minutes, replacement of all breathing circuits and CO2 absorbent and removal of vaporizers

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30
Q

LIter flow of carrier gas is related to

A

air, oxygen, and nitrous oxide (less soluble so is able to bring gas along with it)

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31
Q

What accelerates agent intake?

A

increasing liter flows

32
Q

Why would we give 100% oxygen prior to induction?

A

we denitrate them because we’re creating a situation where they’re oxygenated prior to intubating them

33
Q

What is blood: gas solubility?

A

describes the amount of gas that will dissolve or bind to the blood versus the amount that will diffuse into the tissues
soluble agents remain in the blood longer, so less is released into the tissues during uptake (it will be slower)

34
Q

Isoflurane has a solubility coefficient of 1.4 this means that

A

1.4 times more gas is bound to blood than is available to the tissues

35
Q

If you have a gas with a solubility coefficient of 1.4 versus a solubility coefficient of 0.42, which drug would put you to sleep quicker?

A

0.42

36
Q

If you have a gas with a solubility coefficient of 1.4 versus a solubility coefficient of 0.42, which drug would you wake up quicker from?

A

0.42 drug

37
Q

A gas that is more potent, has

A

a lower MAC

38
Q

The lower the blood gas solubility coefficient

A

the faster the rate of rise in the lung and brain concentrations

39
Q

How could you make a gas with a high solubility coefficient more like desflurane with a low solubility coefficient?

A

add nitrous oxide

40
Q

The rate and depth of ventilation influences

A

the uptake on induction and removal on emergence
if we hyperventilate someone, you will increase the
amount of gas more quickly; you can also
hyperventilate someone to get rid of gas but this also
blows off CO2 so they don’t want to breathe

41
Q

Ventilation perfusion defects alter

A

the rate of uptake
gases with a low blood solubility coefficient
affected to a greater extent

42
Q

Oil:gas solubility is

A

an indicator of potency
indicator of ability to get into the tissues
highly lipid-soluble drugs tend to be more potent
isoflurane most potent; nitrous oxide least potent

43
Q

Compare blood:gas to oil:gas solubility

A

blood: gas- ability to get into body
Oil: gas- ability to get into the tissues

44
Q

The second-gas effect is

A

co-administration of a slower agent with nitrous oxide to speed the onset of the slower agent
can also be used during emergence to quickly remove a slower gas

45
Q

The concentration or dose effect is

A

administration of a higher concentration of gas than necessary to speed up initial uptake
greater effect on high solubility gases

46
Q

An increase in cardiac output

A

slows uptake of gas because blood spends less time in the lungs which slows the rise in lung/brain concentration
high solubility anesthetic gases are affected more
(isoflurane)

47
Q

The circulatory system has two major influences on anesthetic gases:

A

uptake and distribution

Majority of blood leaving the heart is distributed to the vessel rich organs or central compartment

48
Q

Decreases in temperature results in increased:

A

potency & solubility

49
Q

Hypothermia decreases tissue perfusion resulting in

A

slowed induction

50
Q

Hypothermia increases tissue

A

anesthetic capacity which leads to slow recovery

51
Q

Hyperthermia increases

A

cardiac output and anesthetic requirement which also slows induction

52
Q

How are modern anesthetics metabolized?

A

they’re minimally metabolized so toxic metabolites do not present a clinical issue

53
Q

Which modern anesthetics are not metabolized?

A

nitrous oxide, desflurane, and isoflurane

54
Q

Where is sevoflurane metabolized?

A

approximately 5-8% of sevoflurane is metabolized by the liver releasing free fluoride ions

55
Q

What was Ether day?

A

March 30, 1842 William T.G. Morton successfully removed a tumor at Mass Gen

56
Q

When was nitrous oxide discovered?

A

1790s by Joseph Priestley

1842 Horace Wells used it for a dental procedure but not as successful when he demonstrated use at Mass Gen

57
Q

Halothane was developed in

A

1956 & was the first halogenated anesthetic agent
it was a major break through because it was non-flammable but it is metabolized in the liver so halothane hepatitis was possible

58
Q

Chloroform was discovered in

A

1831 by Dr. Samuel Guthrie

non-flammable but highly potent which resulted in many deaths

59
Q

Anesthetic leaves the blood via

A

the lungs with ventilation

60
Q

Diffusion hypoxia can occur

A

Patients who were receiving nitrous oxide during a case should receive 100% oxygen on emergence in order to get rid of nitrous from the lungs but this can cause diffusion atelectasis (utilizing 100% fiO2)

61
Q

Emergence tends to be smoother than induction

A

after longer cases

less so in younger patients

62
Q

The longer an anesthetic gas is used during the case

A

the slower the emergence

63
Q

The higher the solubility

in regards to emergence

A

the slower the emergence (isoflurane>sevoflurane>desflurane>nitrous oxide)

64
Q

Definition of diffusion hypoxia

A

when high concentrations of insoluble anesthetics such as nitrous oxide are delivered, it quickly exits the lungs during emergence and is replaced by nitrogen resulting in dilution of less soluble gases such as oxygen and carbon dioxide
delivering 100% oxygen for several minutes prior to
emergence prevents this phenomenon

65
Q

What happens in emergence phase 1?

A

cessation of anesthetic drugs, reversal of NMBD, transition from apnea to breathing, increased alpha and beta waves on EEG

66
Q

What happens in emergence phase 2?

A

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

67
Q

What happens in emergence phase 3?

A

eye opening, responds to verbal commands, awake EEG patterns, extubation possible

68
Q

How does obesity impact anesthetics?

A

minimal impact on uptake, prolonged cases may prolong emergence due to deposit of anesthetic into adipose tissue

69
Q

How does pregnancy impact anesthetics?

A

higher minute ventilation but higher CO counterbalances

70
Q

How does cardiopulmonary bypass impact anesthetics?

A

higher concentrations required than under normal lung ventilation
uptake and elimination is inversely related to blood:gas solubility

71
Q

How does left-to-right shunts impact anesthetic gas?

A

increases uptake of anesthetic in mixed venous blood

slight increase in uptake to the brain, tissue, and muscle

72
Q

How do right-to-left shunts impact anesthetic gas?

A

(PE) shunted blood mixes and dilutes blood coming from ventilated alveoli reducing anesthetic partial pressure and slows induction
insoluble agents are affected more

73
Q

Because nitrous oxide is 34 times more soluble than nitrogen, when nitrous oxide is administered during a case,

A

it will readily diffuse into air-containing cavities, increasing the volume
Rigid air-containing spaces will undergo increased pressure

74
Q

What cases are we concerned with usage of nitrous oxide and air cavities?

A 
ENT- tympanic space/ eyes
intracranial vault
air emboli cases
air filled cuffs on ET tube and pulmonary artery catheters 
free air in bowel (bowel obstruction)
75
Q

Pediatric-related factors of anesthetic gases include:

A

anesthetic uptake greater in pediatric patients than adults d/t decreased muscle mass so higher concentration in vessel rich tissue
anesthetic agents less soluble in children than adults
a six month old has 1.5-1.8 times the MAC
requirement of a 40 year old adult

76
Q

Emergence delirium is

A

more common in infants, children, and young adults and can be attenuated with administration of dexmedetmoidine, fentanyl, and ketamine

Pharmacology Sem 1 (14 decks)

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