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IV Anesthetics Flashcards

1
Q

What is the chemical name and class of Propofol?

A

2,6 - Diisopropylphenol

isopropylphenol

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2
Q

What is the mechanism of action of propofol?

A

Direct GABA-A agonist -> ↑ Cl conductance -> neuronal hyperpolarization

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3
Q

What is the induction and infusion dose of Propofol?

Are they based on LBW or TBW?

A

induction: LBW, 1.5-2.5 mg/kg
Maintenance: TBW, 25-200mcg/kg/min

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4
Q

What is the onset and duration of propofol?

A

onset: 30-60 sec
duration: 5-10 minutes

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5
Q

How is propofol metabolized?

A

Liver by P450 enzymes and extra hepatic metabolism (lungs)

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6
Q

What does the preservative in Propofol contain?

A

EDTA

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7
Q

Describe pharmacokinetics of propofol.

A

Blood concentration declines over time. Rapid distribution to VRG. Redistributes to muscle then fat.

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8
Q

The concentration of propofol in the brain peaks at what time interval?

A

1 minute

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9
Q 
How does propofol affect...
BP
SVR
venous tone
myocardial contractility
A

all decrease

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10
Q

How does propofol shift the CO2 response curve?

A

down and to the right (less sensitive to CO2)

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11
Q

What effect does propofol have on hypoxic ventilatory drive?

A

inhibits hypoxic ventilatory drive

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11
Q 
How does propofol affect...
CMRO2
Cerebral blood flow
Intracranial pressure
Intraocular pressure
A

decrease all

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12
Q

What doses of propofol is used as an antipruritic and antiemetic effect?

A

antipruritic: 10mg
antiemetic: 10-20mg

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13
Q

Can you give propofol to a patient with a egg allergy?

A

yes, they are likely allergic to the egg white. Propofol comes from the yolk

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14
Q

What can long term propofol infusion cause? What is it?

A

propofol infusion syndrome. Starves cells of O2, particularly cardiac and skeletal

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15
Q

What are some signs of propofol infusion syndrome?

A

bradycardia-> asystole, metabolic acidosis, rhabdo, enlarged liver,

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16
Q

What are risk factors for propofol infusion syndrome?

A 
dose > 4 mg/kg/hr (67 mcg/kg/min) 
Infusion duration > 48 hours
Children > adults
Inadequate oxygen delivery
Sepsis
Significant cerebral injury
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17
Q

When should a syringe and infusion of propofol be discarded?

A

syringe: 6 hours
infusion: 12 hours

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18
Q

Should branded or generic propofol be avoided in asthmatics and infants?

A

generic. due to preservatives
metabisulfite causes bronchospasm
benzyl alcohol should be avoided in infants

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19
Q

How can propofol injection pain be avoided?

A

lidocaine before
larger vein
opioid before

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20
Q 
Fospropofol is (select 2)
a lipid emulsion
prodrug
pain at injection site
metabolized by alkaline phosphate
A

prodrug

metabolized by alkaline phosphate

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21
Q

What IV induction agent causes genital and anal during on injection?

A

fospropofol

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22
Q

What is the chemical name and class of fospropofol?

A

Phosphono-O-methyl-2,6-diisopropylphenol

Isopropylphenol

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23
Q

Is fospropofol a lipid emulsion or aqueous solution?

A

aqueous solution. doesnt support bacterial growth

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24
Q

What is the mechanism of action of fospropofol?

A

Is a prodrug, metabolized to propofol by alkaline phosphatase. Slow onset and long duration

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25
Q

What is the induction and repeat dose of Fospropofol?

A

induction: 6.5mg/kg

repeat bolus: 1.6mg/kg q4min

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26
Q

What is the onset and duration of fospropofol?

A

onset: 5-13 minutes
Duration: 15-45 minutes

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27
Q

How is fospropofol metabolized?

A

liver by P450 enzyme and extrahepatic metabolism (lungs)

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28
Q

What is the extraction ratio of propofol and fospropofol? What does this mean?

A

ER > 0.7

Clearance is dependent on liver BLOOD FLOW.

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29
Q

What is the active metabolite of fospropofol?

A

propofol!

Formaldehyde is metabolized to formate & excreted in urine

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30
Q

What is the chemical name and class of ketamine?

A

2-(o-Chlorophenyl)-2 (methylamino) cyclohexanone hydrochloride
Arylcyclohexylamine- Phencyclidine derivative

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31
Q

What kind of mixture is ketamine and its pKA?

A

racemic mixture

pKA 7.5

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32
Q

What is the MOA of ketamine?

A

NMDA receptor antagonist

dissociates the thalamus from the limbic system

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33
Q

What are secondary receptor targets of ketamine?

A

opioid, MAO, serotonin, NE, muscarinic, Na channels

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34
Q 
What are the doses of ketamine?
Induction:
maintenance:
low dose infusion:
analgesia:
A

Induction: 1-2mg/kg
maintenance: 1-3mg/kg
low dose infusion: 1-3mg/kg
analgesia: 0.1-0.5 mg/kg

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35
Q

What is the IM and oral dose of Ketamine?

A

IM: 4-8mg/kg
oral: 10mg/kg

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36
Q

What is the IV and IM onset and duration of Ketamine?

A

IV: 30-60 seconds, IM: 2-4 minutes
DOA: 10-20 minutes, 60-90 min for full orientation

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37
Q

Where is Ketamine cleared from the body?

A

liver by P450 enzymes

chronic use causes rapid escalation of tolerance

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38
Q

What is the active metabolite of ketamine? What is its potency?

A

norketamine, 1/3 - 1/5 the potency

renal excretion

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39
Q 
What does ketamine do to...
SNS tone 
Cardiac output
HR
SVR
Pulmonary vascular resistance
A

increase all

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40
Q

When is ketamine a myocardial depressant?

A

patient with depleted catecholamine stores or sympathetectomy

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41
Q

Is ketamine a better analgesic for visceral or somatic pain?

A

somatic

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42
Q

What IV induction agent is a great choice if the patient is actively wheezing?

A

ketamine, its a bronchodilator

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43
Q

How does ketamine alter the CO2 response curve and respiratory drive?

A

it doesnt!

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44
Q

What medication is prudent to give your patient after giving ketamine?

A

glycopyrrolate. It increases secretions

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45
Q 
How does ketamine affect....
CMRO2
Cerebral blood flow
ICP
Intraocular pressure
EEG activity
A

increases all

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46
Q

Why is ketamine contraindicated in eye surgery?

A

causes nystagmus

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47
Q

What is the best medication to give to prevent emergence delirium in a patient that received ketamine?

A

Midazolam before ketamine administration. Also diazepam

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48
Q

What are risk factors for emergence delirium from ketamine?

A

age > 15 years, females, ketamine dose > 2 mg/kg, hx of personality disorder

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49
Q

In order to prevent hyperalgesia following remifentanil infusion what IV induction agent can you give?

A

ketamine

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50
Q

Where does ketamine block central sensitization and wind up in the spinal cord?

A

dorsal horn

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51
Q

What can chronic ketamine use cause?

A

ulcerative cystitis

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52
Q

Ketamine should be avoided in what patient?

A

acute intermittent porphyria

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53
Q

Which IV induction agent undergoes the smallest amount of plasma protein binding?

A

ketamine

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54
Q

What is the chemical name and class of etomidate?

A

R-1-methyl-1-(a-methylbenzyl) imidazole-5-carboxylate Imidazole

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55
Q

How does an acidic pH and physiologic pH affect solubility of etomidate?

A

acidic pH: water soluble

physiologic pH: lipid soluble

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56
Q

What are the two formulations of etomidate?

A

35% propylene glycol: venous irritation and pain

lipid emulsion: less pain

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57
Q

What is the MOA of etomidate?

A

GABA-A agonist

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58
Q

What is the induction dose of etomidate?

A

0.2-0.4mg/kg

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59
Q

What is the onset and DOA of etomidate?

A

onset: 30-60 seconds
DOA: 5-15 minutes

60
Q

How is etomidate cleared from the body?

A

P450 enzymes and plasma esterases

61
Q

Is rapid awakening from etomidate caused by metabolism or redistribution?

A

redistribution off receptors

62
Q

What are the cardiac effects of etomidate?

A

hemodynamic stable
slight decrease in BP
does not block SNS response to laryngoscopy

63
Q

What effect does etomidate have on the respiratory system?

A

mild depression

64
Q

How does etomidate affect…
CMRO2
CBF
ICP

65
Q

Which IV anesthetic is most likely to cause PONV?

66
Q

What is a side effect of etomidate d/t imbalance between excitatory & inhibitory pathways in the thalamocortical tract?

A

myoclonus. Not seizure

67
Q

Does etomidate increase the risk of seizures?

A

only if they have a history of seizures

68
Q

What IV induction agent is useful for mapping seizure foci?

69
Q

What are the two enzymes that etomidate inhibits?

A

11-beta-hydroxylase & 17-alpha-hydroxylase

70
Q

Why should etomidate be avoided in patients with sepsis, acute adrenal failure or Addisonian crisis?

A

decreases adrenocortical function for 5-8 hours

71
Q

What induction agents should be avoided in patient with acute intermittent porphyria?

A

etomidate, ketamine

72
Q

What barbiturate has a sulfur molecule in the second position?

A

thiopental

73
Q

What barbiturates have a oxygen molecule in the second position?

A

methohexital, pentobarbital

74
Q

Methohexital has a methyl group on the nitrogen atom. What does this cause?

A

lower seizure threshold and increases potency

75
Q

Phenobarbital has a phenyl group at the 5 carbon, what does this do?

A

increases anticonvulsant effect

76
Q

What is the chemical name and class of thiopental?

A

5-ethyl-5-(1-methylbutyl)-2-thiobarbituric acid

Barbiturate

77
Q

Is thiopental water or lipid soluble?

A

water soluble

78
Q

What is the pH of thiopental? What is the danger of this?

A

pH 9. Precipitates if mixed with an acidic solution.

79
Q

What does thiopental cause if given arterially?

A

vasoconstriction, crystal formation, tissue necrosis

80
Q

What is the MOA of thiopental?

A

GABA-A agonist -> Depresses the reticular activating system in brainstem.

81
Q

What are the different effects of low and high dose thiopental?

A

Low/normal dose: Increases the affinity of GABA for its binding site
High dose: Directly stimulates the GABA-A receptor

82
Q

What are the adult and child doses of thiopental?

A

adult: 2.5-5mg/kg
child: 5-6mg/kg

83
Q

What is the onset and DOA of thiopental?

A

onset: 30–60sec
DOA: 5–10min

84
Q

Where is thiopental cleared?

A

P450 enzymes

85
Q

What two IV induction agents is awakening determined by redistribution and not metabolism?

A

thiopental and etomidate

86
Q

What is the active metabolite of thiopental?

A

normal dose: none

high dose: phenobarbital

87
Q

What medication is the gold stardard for use during an ECT?

A

methohexital

88
Q

What is the mechanism of methohexital?

A

decreases seizure threshold and produces a better seizure

89
Q

What is the induction dose of methohexital?

A

1-1.5mg/kg

90
Q

What are the cardiovascular side effects of barbiturates?

A

hypotension and histamine release. Baroreceptor reflex remains intact

91
Q

How does barbiturates shift the Oxygen-Hgb dissociation curve?

A

to the right. more unloading of O2

92
Q

How do barbiturates affect:
CMRO2
CBF, ICP
EEG activity

A

decrease all

93
Q

Do barbiturates cause global or focal ischemia?

94
Q

What is the most common and dangerous form of porphyria?

A

acute intermittent

95
Q

What causes poryphria?

A

defect in heme synthesis that promotes accumulation of heme precursors

96
Q

What causes an exacerbation of acute intermittent porphyria?

A

stimulation of ALA synthase, emotional stress, NPO, CYP450 induction

97
Q

What drugs should be avoided in a patient with acute intermittent porphyria?

A

barbiturates, etomidate, ketamine, ketorolac, amiodarone, CCBs, birth control

98
Q

What are presentation symptoms of acute intermittent porphyria?

A

abdominal pain (#1), psychiatric symptoms, delirium, seizures, neuropathy, & coma

99
Q

What is the anesthetic management of the patient with acute intermittent poryphria?

A

liberal fluids, glucose supplements, heme arginine, prevent hypothermia

100
Q

What is the treatment of intra-arterial injection of thiopental?

A

phentolamine, phenoxybenzamine

101
Q

What is the chemical name and class of dexmeditomidine?

A

(S)-[1-(2,3-Dimethylphenl)ethyl]-1H-imidazole monohydrochloride
Imidazole

102
Q

What is the pKA of dexmedetomidine?

103
Q

What is the MOA of dexmedetomidine?

A

alpha 2 agonist. decreases cAMP, which inhibits the locus coeruleus in the pons causing sedation

104
Q

what are the loading and maintenance doses of dexmedetomidine?

A

loading: 1mcg/kg over 10 minute
maintenance: 0.4-0.7 mcg/kg/hr

105
Q

what is the onset and duration of dexmedetomidine?

A

onset of loading dose is 10-20 minutes

duration 10-30 minutes after stopping

106
Q

What is responsible for clearance of dexmedetomidine from the body?

A

Liver, P450 enzymes

107
Q

Does dexmedetomidine have an active metabolite?

108
Q

What are the most common side effects of dexmedetomidine?

A

HoTN and bradycardia

109
Q

What is the mechanism for dexmedetomidine causing HTN after rapid injection?

A

peripheral alpha 2 stimulation. Central stimulation quickly overcomes peripheral alpha 2 stimulation

110
Q

How does dexamethasone affect the respiratory system?

A

It doesnt. NO RESPIRATORY DEPRESSION

111
Q

How does dexmedetomidine affect:
CBF
CMRO2
ICP

A

CBF decreases
CMRO2 not affected
ICP not affected

112
Q

Where does dexmedetomidine produce analgesia?

A

dorsal horn of spinal cord. decreases substance P and glutamate release

113
Q

What is the dose of dexmeditomidine for preop sedation for kids? When do you give it?

A

3-4mcg/kg 1 hour prior. Nasal or buccal route

114
Q

What is the chemical name and class of midazolam?

A

8-chloro-6-(2-fluorophenyl)-1-methyl-4 H-imidazole[1,5-a][1,4]benzodiazepine
Benzodiazepine

115
Q

What is special about the structure of midazolam and alterations in pH?

A

imidazole ring.
in acidic pH its H2O soluble
at physiologic pH its lipid soluble

116
Q

What is the MOA of midazolam?

A

GABA-A agonist. Increases frequency of channel opening leading to neural hyperpolarization

117
Q

GABA-A agonist increase channel open _____

Benzos increase channel open _____

A

GABA-A agonist increase channel open time

Benzos increase channel open frequency

118
Q

What is the sedation dose, and induction dose of midazolam?

A

sedation: 0.01-0.1 mg/kg
induction: 0.1-0.4 mg/kg

119
Q

What is the dose of oral midazolam for kids?

A

0.5-1 mg/kg

120
Q

What is the onset and duration of midazolam?

A

onset: 30-60 seconds
duration: 20-60 minutes

121
Q

How is midazolam cleared from the body?

A

liver by P450 enzymes

122
Q

What is the active metabolite of midazolam?

A

1-hydroxymidazolam, 0.5x the potency

123
Q

What are cardiac effect of induction doses of midazolam?

A

decreased BP and SVR

124
Q

What medications given with midazolam potentiates the respiratory depression with induction doses?

125
Q

What patients are very sensitive to induction doses of midazolam?

A

COPD due to respiratory depression from induction doses

126
Q

What are CNS side effects of induction doses of midazolam?

A

decreased CMRO2 and CBF

127
Q

What are the three A’s of midazolam CNS side effects?

A

Anterograde amnesia
Anticonvulsant
Anxiolysis

128
Q

What is the elimination 1/2 time of diazepam?

A

43 hours due to enterohepatic recirculation

129
Q

What medications can be used to prevent emergence delirium from Ketamine?

A

midazolam and diazepam

130
Q

Diazepam causes skeletal muscle relaxation, right?

131
Q

Amnestic effects of Lorazepam can last for how many hours?

132
Q

Is Lorazepam a good choice to use as an anticonvulsant?

A

No, it has a slow onset

133
Q

Rank the benzos from greatest to least potent?

A

Lorazepam > midazolam > diazepam

134
Q

Do benzos cause antegrade or retrograde amnesia?

A

antegrade amnesia (memories after administration)

135
Q

What is the additive in diazepam and lorazepam that causes venous irritation?

A

propylene glycol

136
Q

What is the initial dose of Flumazenil given?

137
Q

What is the MOA of flumazenil?

A

a competitive antagonist at the GABA-A receptor

138
Q

What is flumazenil used to reverse?

A

benzodiazepines

139
Q

Does Flumazenil increase SNS tone, anxiety, or neuroendocrine evidence of stress?

140
Q

Does Flumazenil reverse the sedative or amnestic effects of benzos more?

A

the sedative effects more than the amnestic effects

141
Q

Name that IV anesthetic!

142
Q

Name that IV anesthetic!

A

Fospropofol

143
Q

Name that IV anesthetic!

144
Q

Name that IV anesthetic!

145
Q

Name that IV anesthetic!

A

Thiopental

146
Q

Name that IV anesthetic!

A

Dexmedetomidine

147
Q

Name that IV anesthetic!

1 APEX (9 decks)

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