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IV anesthetics Flashcards

1
Q

IVAA which has intrinsic analgesic property

A

Ketamine

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2
Q

IVAA which has antiemetic and appetite stimulating property

A

Propofol

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3
Q

IVAA with amnestic and anxiolytic property

A

Midazolam

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4
Q

Adjuvants for IVAA to produce TIVA

A

Opioid

LAA

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5
Q

MoA of Barbiturates

A

Depress RAS
Inhibit ACh
Enhance GABA

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6
Q

First barbiturate used

A

Hexobarbital

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7
Q

Gold standard of IV anesthetic inductional agent

A

Thiopental

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8
Q

Advantages of thiopental

A

Fast induction time
Fast recovery time
Fast elimination time

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9
Q

Disadvantages of thiopental

A

Localized pain on injection
Excitatory side effect
Induce tachycardia

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10
Q

IVAA widely used in dental anesthesia and day-case surgery

A

Thiopental

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11
Q

Effect of replacing Oxygen (oxybarbs) by Sulfur (thiobarb)

A

Increase lipid solubility

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12
Q

Barbiturate available for rectal administration

A

Thiopental

Methohexital

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13
Q

Barbiturate available for IM

A

Pentobarbital

Secobarbital

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14
Q

Property of Thiopental

A

High PPB
High lipid solubility
High non-ionized fraction

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15
Q

Redistribution time of thiopental

A

20-30 min

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16
Q

Effect of repeated dosage on redistribution

A

Peripheral compartment saturates

DOA becomes dependent on elimination

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17
Q

What does awakening depend upon?

A

Redistribution

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18
Q

What does recovery of psychomotor function depend upon?

A

Metabolism

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19
Q

More rapidly metabolized barbiturate

A

Methohexital (3-4X)

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20
Q

Factors that determine elimination of drug and recovery time

A

Elimination of drug from central compartment
Amount of drug present in the peripheral compartment
Rate of redistribution from peripheral into central compartment

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21
Q

Effect of high PPB on elimination

A

Decreases glomerular filtration

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22
Q

Effect of Barbiturate on CVS

A

Fall in BP
Rise in HR
Maintained CO
Sympathetic induced vasoconstriction (Increased PVR)

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23
Q

Factors that determine CVS effects of barbiturates

A

Volume status
Baseline autonomic tone
Pre-existing CVS disease
Rate of injection

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24
Q

Effect of Intra-arterial injection of barbiturate

A

Crystal formation in artery and capillary
Intense vasoconstriction
Thrombosis
Tissue necrosis

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25
Q

Remedy for Intra-arterial injection of barbiturate

A 
IA injection of lidocaine
Regional sympathectomy (brachial plexus block)
Heparinization
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26
Q

Effect of Barbiturate on Respiratory system

A

Decrease response to hypercapnia and hypoxia
Does not completely depress airway reflex
Apnea
UAW obstruction (sedation)

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27
Q

Barbiturate more commonly associated with laryngospasm and hiccup

A

Methohexital

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28
Q

Cause for Bronchospasm after induction of thiopental + Remedy

A

Cholinergic nerve stimulation
Histamine release
Direct bronchial smooth muscle stimulation

Remedy
Atropine pre-treatment

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29
Q

Effect of Barbiturate on CNS

A

Decrease CBF + CMRO2
Decrease ICP
Increased CPP (drop in ICP exceede drop in MAP)

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30
Q

Which barbiturate relates a sense of taste of garlic/onion during induction

A

Thiopental

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31
Q

Which group of IVAA has an anti-analgesic effect (lower the pain threshold)

A

Barbiturates

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32
Q

Which IVAA are known to develop tolerance and dependence

A

Barbiturate

Ketamine (partial tolerance)

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33
Q

Which barbiturate induces involuntary muscle contraction)

A

Methohexital

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34
Q

What is the effect of Barbiturate on Renal system

A

Reduce RBF and GFR proportional to fall in BP

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35
Q

What is the effect of Barbiturate on Liver

A

Reduced Hepatic BF
Liver enzyme induction upon chronic exposure
Increase metabolic rate of some drugs (digitoxin)

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36
Q

Which group of barbiturates evoke mast cell histamine release

A

Thiopental (Sulfur containing barbiturate)

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37
Q

What are drugs that could increase/potentiate barbiturates?

A 
Sulfonamide
Ethanol
Opioids
Antihistamine
Other sedatives
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38
Q

Propofol (Vs Thiopental)

A

Higher lipid solubility
Faster onset
Rapid recovery
Less hangover

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39
Q

Adjuvants of Propofol

A

10% soybean oil

  1. 25% glycerol
  2. 2% egg Lecithin
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40
Q

Remedy of pain on injection of propofol

A

Using larger veins

Prior administration of LAA or opioid (fentanyl, remifentanil)

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41
Q

Sodium metabisulfite in propofol

A

Newer formulations
Antimicrobial additive
Less pain on injection

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42
Q

Concentration and Dose of Thiopental induction

A

2.5-5%

3-6 mg/kg

43
Q

Concentration and Dose of Thiopental sedation

A
  1. 5%

0. 5-1.5 mg/kg

44
Q

Concentration and Dose of Methohexital induction

A

1%

1-2 mg/kg

45
Q

Concentration and Dose of Methohexital sedation

A

1%

0.2-0.4 mg/kg

46
Q

Dose of Propofol induction

A

1.5-2.5 mg/kg

47
Q

Reasons for higher induction and maintenance dose for children for propofol

A

Large central distribution volume

Higher clearance rate

48
Q

IVAA with a subjective feeling of well-being (euphoria)

49
Q

Metabolism of propofol

A

10X clearance rate of thiopental
Clearance exceeds hepatic BF (extrahepatic metabolism)
Conjugation in liver results in inactive metabolite

50
Q

Elimination of propofol

A

Eliminated by renal clearance

51
Q

Effect of moderate cirrhosis and chronic renal failure on propofol

A

Not much effect on its pharmacokinetic property

52
Q

Infusion of propofol for long-term sedation of children or neurosurgical patient

A

Lipemia
Metabolic acidosis
Death

53
Q

Effect of Propofol on CVS

A 
Drop in SVR
Drop in contractility
Drop in preload
Vagally mediated reflex bradycardia
More pronounced hypotension
Coronary steal syndrome
54
Q

Effect of Propofol on Respiratory system

A 
Profound depressant
Apnea at induction
Depress UAR
Laryngeal placement without paralysis
Histamine release
55
Q

Effect of Propofol on CNS

A 
Decrease CBF
Decrease ICP
Decrease IOP
Anticonvulsant
No tolerance development
56
Q

Drugs that are potentiated by Propofol

57
Q

MoA of Propofol

A

Facilitate GABA

58
Q

MoA of Etomidate

A

Depress RAS

Disinhibitory effect on extrapyramidal motor activity

59
Q

Dosage of Etomidate for Induction

A

0.2-0.5 mg/kg

60
Q

Metabolism of Etomidate

A

Hepatic microsomal enzyme
Plasma esterase
Fast metabolism (5X of thiopental)

61
Q

Excretion of Etomidate

A

Primarily excreted in urine

62
Q

Which IVAA has minimal effect on CVS

63
Q

Effect of Etomidate on Respiratory system

A

Less respiratory depression (unless combined with opioid)

64
Q

Effect of Etomidate on CNS

A

Decrease CBF, CMRO2
Decrease ICP
CPP well maintained
Postoperative nausea and vomiting

65
Q

Which IVAA leads to adrenocortical suppression

66
Q

Which drug prolongs the half-life of Etomidate

67
Q

MoA of Ketamine

A

NMDA antagonist
Blocks polysynaptic reflexes in the SC
Inhibits excitatory NT

68
Q

Which IVAA produces dissociative anesthesia

69
Q

Two isomers of Ketamine

A

S+ and R-

S+ more potent anesthetic and analgesic

70
Q

Dosage of Ketamine Induction IV

71
Q

Dosage of Ketamine Induction IM

72
Q

Dosage of Ketamine Sedation IV

A

0.1-0.5 mg/kg

73
Q

Dosage of Ketamine Sedation IM

A

1-1.5 mg/kg

74
Q

Property of Ketamine

A

More lipid soluble
Less protein bound
Equally ionized

Vs thiopental

75
Q

Metabolism of Ketamine

A

Hepatic microsomal CP450

76
Q

Metabolite of Ketamine

A

Nor-ketamine

77
Q

Excretion of Ketamine

A

Excreted Renally

High hepatic clearance rate

78
Q

Effect of Ketamine on CVS

A

Increase BP, HR and CO

79
Q

Counter-indication for Ketamine

A 
CAD
Uncontrolled HTN
CHF
Aneurysms
Space occupying intracranial lesion
80
Q

Effect of Ketamine on Respiratory system

A

Minimally affect at induction dose
Rapid/Repeated/Opioid coadmin causes apnea
Potent bronchodilator (for asthmatic patient)
Intact UAR

81
Q

Effect of Ketamine on CNS

A

Increases CMRO2
Increases CBF
Increases ICP
Psychomimetic effect

82
Q

What drugs does Ketamine potentiate

A

Non-depolarizing muscle relaxants

83
Q

What two drugs mixture would form dangerous precipitation that would occlude IV line

A

Ketamine

Thiopental

84
Q

MoA of BDZ

A

Enhance inhibitory NT

Increase conductance of Cl-

85
Q

Receptor occupancy required to achieve anxiolysis, amnesia-sedation, hypnosis?

A

20%
30-50%
60%

86
Q

Hydrophobic BDZ

A

Diazepam (Valium)

Lorazepam (Ativan)

87
Q

Water soluble BDZ

A

Midazolam
acidified (3.5) aqueous formulation
minimal irritation

Physiologic pH
Change of physico-chemical property (lipid soluble)

88
Q

BDZ specific receptor antagonist

A

Flumazenil

89
Q

BDZ that are well absorbed from GIT + peak plasma level

A

Diazepam (1hr)

Lorazepam (2hr)

90
Q

BDZ available in Intranasal, buccal and sublingual for children

91
Q

Redistribution and Property of BDZ

A

Rapid redistribution

Can’t match rapid onset and offset of thiopental

92
Q

Lorazepam Vd, half life and duration

A

Vd limited by lower lipid solubility
Shorter half life (15 hrs)
Prolonged duration due to high receptor affinity

93
Q

Midazolam Vd, half life and duration

A

Large Vd
Small half life (2hrs)
Shortest duration due to high hepatic extraction

94
Q

Excretion of BDZ

95
Q

Excretion of Midazolam in Renal failure patient

A

Prolonged sedation

Accumulation of conjugated metabolite (a-hydroxymidazolam)

96
Q

Effect of BDZ on CVS

A

Minimal CVS depressant at induction dose
Masked by laryngoscopic stimulation
More marked in hypovolemic patient

97
Q

Midazolam vs Diazepam (CVS)

A

Midazolam reduces BP, PVR more

Drug induced vagolysis by Midazolam

98
Q

Effect of BDZ on Respiration

A

Depress ventilatory response to CO2
Apnea uncommon
Depress swallowing reflex
Reduce UAR

99
Q

Effect of BDZ on CNS

A

Reduce CMRO2, CBF, ICP less than barbs
Slower hypnosis
Longer recovery
Treatment of Status epilepticus

100
Q

Drug that binds to CP450 and reduce diazepam metabolism

A

Cimetidine

101
Q

Drug that inhibit midazolam metabolism and cause 2-3 increased intensity

A

Erythromycine

102
Q

Displaces diazepam from protein-binding site and increase free drug concentration

103
Q

Metabolism and excretion of Flumazenil

A

Rapid metabolism in Liver

Excreted in urine as glucuronide conjugate

Basics of Anesthesia (4 decks)

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