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KM (Spring 2024) Anesthesia Pharm ** > Local Anesthetics II (Exam IV) > Flashcards

Local Anesthetics II (Exam IV) Flashcards

1
Q

What is the average pKa of local anesthetics?

A

8

S42

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2
Q

What is the function of the Alkalinization of LA Solutions?

What are the benefits of alkalinization?

A

Alkalinization increases the percentage of lipid-soluble or non-ionized forms.

  • Faster onset of action
  • Speeds onset of peripheral and epidural blocks by 3 to 5 mins.
  • Enhances the depth
  • Increase the spread (i.e., epidural)

S42

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3
Q

Regarding weak bases, the pKa is ________ pH.

A

before

ex. pKa 9, pH 7 → 9 - 7 = +2

S44

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4
Q

Regarding weak acids, the pKa is ________ pH.

A

after

ex. pKa 9, pH 7 → 7 - 9 = -2

S44

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5
Q

Nicely negative numbers are _________.

A

non-ionized

S44

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6
Q

If Drug V (weak base) has a pKa of 9.1, will the drug be more ionized or nonionized at physiological pH?

A

pKa - pH
9.1 - 7.4 = +1.7

Drug V will be more ionized at physiological pH.

Weak Bases, pKa before pH
Weak Acids, pKa afterpH

S44

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7
Q

If the pKa of LA (a weak base) is at 4.5, will the drug be more ionized or nonionized at physiological pH?

A

pKa - pH
4.5 - 7.4 = -2.9

LA will be more non-ionized at physiological pH.

Weak Bases, pKa before pH
Weak Acids, pKa afterpH

S44

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8
Q

LA1’s pKa is 9.2, and LA2’s pKa is 7.5. Which of the following are correct when placed in physiological pH? Select 2 answers.

A. LA2 has more non-ionized components
B. LA1 has more ionized components
C. LA2 has more ionized components
D. LA1 has more non-ionized components

A

B and C

LA1
9.2 - 7.4 = +1.8 (ionized)

LA2
7.5 - 7.4 = +0.1 (ionized)

Weak Bases, pKa before pH
Weak Acids, pKa afterpH

S45

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9
Q

What adjuvant medications prolong the duration of local anesthetics?

A
  • Dexmedetomidine
  • Magnesium
  • Clonidine
  • Ketamine
  • Dexamethasone

S46

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10
Q

What will be the results of combining LA Chloroprocaine & Bupivacaine?

A
  • Produce a rapid onset
  • Tachyphylaxis (bupivacaine)

S47

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11
Q

What is added to 30 mL of LA to alkalinize the drug?

A

1 mL of 8.4% Sodium Bicarbonate

This will increase the non-ionized form of LA.
Make sure the mixture does not contain any precipitate.

S47

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12
Q

Combining local anesthetics and getting toxic effects is a synergistic process. T/F ?

A

False. Additive. (1+1 =2)

S47

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13
Q

Compare the onset of action between chloroprocaine and bupivacaine.

A

Chloroprocaine: Rapid
Bupivacaine: Slow

S48

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14
Q

What vasoconstrictors can be utilized with local anesthetics?

A
  1. Epinephrine
  2. Phenylephrine

S49

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15
Q

Why is it important to use vasoconstrictors with LA?

A

The duration of action of a LA is proportional to the time the drug is in contact with nerve fibers.

For this reason, epinephrine may be added to LA solutions to produce vasoconstriction, which limits systemic absorption and maintains the drug concentration in the vicinity of the nerve fibers to be anesthetized.

FIX THIS FLASHCARD

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16
Q

What are the results of using vasoconstrictors with LA?

A
  • Produce vasoconstriction
  • Increased neuronal uptake of LA
  • α-adrenergic effects may have some degree of analgesia
  • No effect on the onset rate of LA
  • Enhanced cardiac irritability with inhaled anesthetics
  • Systemic absorption → HTN (tachycardia)

S49 FIX SLIDE

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17
Q

What is epinephrine 1:200,000 mean?

Convert that to mcg/mL.

A

1:200,000 means 1 gram of epinephrine is dissolved in 200,000 mL of solvent.

  • 1g/200,000 mL
  • 1000mg/200,000 mL
  • 1 mg/200 mL
  • 1000 mcg/200 mL
  • 10 mcg/2 mL
  • 5 mcg/mL

S51

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18
Q

Compute 1:500,000 to mcg/mL

A

2 mcg/mL

  • 1 g/500,000 mL
  • 1000 mg/500,000 mL
  • 1 mg /500 mL
  • 1000 mcg/500 mL
  • 10 mcg/5 mL
  • 2 mcg/mL

Shortcut: 1,000,000 divided by the solvent number. 1 million/500,000 = 2 mcg/mL

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19
Q

How much epinephrine or phenylephrine is given with bupivacaine or lidocaine for a subarachnoid block (SAB)?

A
  • 0.2 mg Epi
  • 2 mg Phenylephrine
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20
Q

Compute 1:500,000 Epi to mcg/mL

A

1,000,000/ 500,000=2

2 mcg/mL

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21
Q

Compute 1:10,000 Epi to mcg/mL

A

1,000,000/ 10,000 = 100

100 mcg/mL

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22
Q

Compute 1:1000 Epi to mcg/mL

A

1,000,000/ 1000 = 1000

1000 mcg/mL

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23
Q

0.25% equates to how many mg per mL ?

A

2.5 mg/mL

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24
Q

0.5% equates to how many milligrams per milliliter?

A

5 mg/mL

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25
Q

1% equates to how many milligrams per mL ?

A

10 mg/mL

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26
Q

2% equates to how many milligrams per mL ?

A

20 mg/mL

2% lidocaine is the most common concentration used in the OR

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27
Q

4% equates to how many milligrams per mL ?

A

40 mg/mL

S52

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28
Q

Your surgeon injected 20 mLs of Bupivacaine 0.25% with 1:200,000 of Epi.

What are the total mgs for Bupivacaine and the total mcgs for Epinephrine?

A

Bupivacaine:
0.25% = 2.5 mgs/mL
2.5 mgs x 20 mLs = 50 mgs total

Epinephrine:
1:200,000 = 5 mcg/mL
5 mcg x 20 mLs = 100 mcg total

S53

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29
Q

What is the Lidocaine Recommended Max Single Dose for Spinal?

A

100 mg

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30
Q

Mepivacaine Recommended Max Single Dose

Mepivacaine Recommended Max Single Dose with/Epi

Mepivacaine Recommended Max Single Dose for Spinal

A

400 mg

500 mg w/ Epi

100 mg

S58

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31
Q

Prilocaine Recommended Max Single Dose

A

600 mg

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32
Q

Bupivacaine Recommended Max Single Dose

Bupivacaine Recommended Max Single Dose with/Epi

Bupivacaine Recommended Max Single Dose for Spinal

A

175 mg

225 mg w/ Epi

20 mg

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33
Q

112.5 mg of Bupivacaine with Epi and 250 mg of Lidocaine with Epi were given during surgery.

What are the percentages of each LA based on the recommended max single dose in mg?

A

Max single dose of Bupivacaine with Epi: 225 mg
112.5/225 = 50%

Max single dose of Lidocaine with Epi: 500 mg
250/500 = 50%

S59

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34
Q

Where are topical anesthetics applicable?

A

Applicable on the mucous membranes of the nose, mouth, tracheobronchial tree, esophagus, or GU tract.

S60

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35
Q

Which anesthetic has localized vasoconstriction that will decrease blood loss and improve surgical visualization?

A

Cocaine (4-10%)

S60

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36
Q

Which anesthetic is great with surface anesthesia?

A

Lidocaine (2-4%)

S60

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37
Q

Lidocaine inhalation does not alter airway resistance, but does cause ______.

A

vasodilation

S60

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38
Q

Which local anesthetics are not effective for topical anesthesia?

A

Procaine and Chloroprocaine

These drugs do not penetrate mucous membranes as effectively as cocaine or lidocaine.

S60

39
Q

What is does LTA stand for?

A
  • Lidocaine tracheal anesthesia
  • Localized tracheal anesthesia

S61

40
Q

What is the % of Lidocaine for LTA? And is this added to the total Lidocaine count?

A

4 mL of 4%

YES! It will be added with total Lidocaine

S61

41
Q

Eutectic Mixture of LA (EMLA) contains what two local anesthetics?
Dose:
Onset:

A

Lidocaine 2.5% + Prilocaine 2.5% = 5% LA
Dose: 1 to 2 g/ 10 cm2 area
Onset: 45 mins

S62

42
Q

EMLA has to be applied for ______ hours before skin graft.

A

2 hours

S62

43
Q

EMLA can be applied for 10 minutes before any of these procedures:

A
  • Cautery of genital warts
  • Venipuncture, lumbar puncture
  • Arterial cannulation (Nitroglycerine)
  • Myringotomy

S62

44
Q

What considerations should one have when using EMLA ?

A
  • Caution with methemoglobinemia
  • No open skin wounds
  • No amide allergy patients

S63

45
Q

Other Topical Anesthesia Preparations besides EMLA

A
  • Amethocaine (EMLA-like)
  • Tetracaine 4% Gel
  • Lidocaine 7%
  • Tetracaine 7%

S63

46
Q

What is considered local infiltration with LA?

A

Extravascular placement of LA (subcutaneous injection)

S64

47
Q

What LAs are used on inguinal operative sites?

A
  • Lidocaine 1% or 2%
  • Ropivacaine 0.25%
  • Bupivacaine 0.25%

S64

48
Q

What are the contraindications of using epinephrine on LA for local infiltrations?

A
  • Not intracutaneously or into tissues at end arteries
  • Fingers, toes, ears, nose, penis

Can cause necrosis.

d/t vasoconstiction ischemia

S64

49
Q

How is Peripheral Nerve Block achieved?

MOA?

A

Achieved by LA injection into tissues surrounding individual peripheral nerves or nerve plexuses.

MOA: diffusion from outer mantle to central core of nerve along a concentration gradient.

* Smallest sensory and ANS fibers first, then larger motor and proprioceptive axons.*

S65

50
Q

What area (proximal or distal) is affected first with local anesthetic administration?

A

The proximal area (site of LA administration) is affected first and then distal.

S65

51
Q

When the peripheral nerve block is wearing off, what comes back first? Proximal or Distal?

A

Proximal comes back first & then distal.

S65

52
Q

Peripheral Nerve Block onset of action is dependent on the local anesthetic’s _________.

53
Q

The duration of a peripheral nerve block depends on the _____ of the local anesthetic.

54
Q

What are the benefits of a continuous infusion block?

A
  • Improved pain control
  • Less nausea
  • Greater satisfaction
  • Additives are used with continuous infusion blocks (ie: Ketolorac, Ketamine, Decadron)

S66

55
Q

slide 67

56
Q

Slide 68

57
Q

Slide 70

58
Q

What is a Regional Bier Block?

A

Bier Block IV injection of LA into an extremity isolated from the rest of the systemic circulation with a tourniquet.

Sensation and muscle tone return dependent on tourniquet release

S71

59
Q

What LA is commonly used in Bier Block?

A

Lidocaine

S71

60
Q

What are the steps to performing a Bier Block?

A

IV start
Exsanguination
Double cuff
LA injection
IV D/C

S72

61
Q

What is the sequence of blockades for a segmental block in Neuraxial Anesthesia?

A
  1. SNS (Myelinated preganglionic B fibers)
  2. Sensory (Myelinated A, B fibers, unmyelinated C fibers)
  3. Motor (Myelinated A-δ and unmyelinated C fibers)

S73

62
Q

Which of the following will be the last sign associated with injection of an anesthetic for neuraxial blockade?

A. NIBP
B. Heart Rate
C. Cold Alcohol Pad
D. Leg Movement

A

D. Leg Movement

we’re assessing motor blockade

Clinical Scenario

63
Q

How is a Spinal Anesthesia Block (SAB) produced?

A

Subarachnoid local anesthetic injection

S74

64
Q

What is used for confirmation of a Spinal Anesthesia Block (SAB)?

65
Q

What is the principal site of action for sub arachnoid block?

A

Preganglionic fiber

66
Q

For SAB, the _______ effect is on the same level of denervation.

A

sensory

S74

67
Q

For SAB, the _______ effect is 2 spinal segments cephalad of the sensory block.

For SAB, the _______ effect is 2 spinal segments below the sensory block.

S74

68
Q

If the sensory block is at T5, where is the SNS block?

A

T3

This SNS block will trigger an asystole event.

S74

69
Q

What dermatomes correspond with our cardiac accelerator?

A

T1 to T4

S74

70
Q

Clinical Scenario Slide:
If the assessed sensory level after SAB is T6 ( Top of Xiphoid Process), what are the blocked SNS and motor levels?

A

SNS Block: T4
Motor Block: T8

S74

71
Q

What are the most common local anesthetics used in SABs ?

A
  • Bupivacaine
  • Levobupivacaine
  • Lidocaine
  • Ropivacaine
  • Tetracaine

S76

72
Q

What factors affect SAB dosage?

A
  • Height of patient (volume of subarachnoid space)
  • Segmental level of anesthesia desired
  • Duration of anesthesia desired

S76

73
Q

For SAB, _____ is more important than _______ of drug (%) or the ______ (mLs) of the solution injection.

A

Dose; Concentration ; volume

S77

74
Q

What is the dose of bupivacaine for the scenario below?

5 ft tall patient = _____mL of 0.75% Bupivacaine
+ ______ mL for every inch above…. 2 cc total ( 1½ hours to 2 hours)

A

1 mL
0.1 mL

For someone who is 5’5”, you will give 1.5 mL of bupivacaine for a SAB.

S77

75
Q

What dose of 0.75% bupivacaine would be indicated for a 6’7” patient undergoing a SAB?

A

2.9mL

1mL for 5ft tall
1.9mL for other 19inches

Clinical question

76
Q

For SAB, the _________ of LA is important in determining the spread of the drug.

A

specific gravity

S77

77
Q

What can be added to LA so that its specific gravity can increase?

What can be added to LA so that its specific gravity can decrease?

A

Glucose added → hyperbaric solution.

Distilled water added → hypobaric solution

S77

78
Q

Which side will you want to position a right-hip arthroplasty patient on if they receive a hyperbaric LA solution?

A

Right side lying, the hyperbaric solution will “sink.”

S77

79
Q

Which side will you want to position a right-hip arthroplasty patient on if they receive a hypobaric LA solution?

A

Left side lying, the hypobaric solution will “float”.

S77

80
Q

The most common LA used in Epidural Anesthesia.

A

Lidocaine

Good diffusion through tissue and safer

S79

81
Q

What is the onset of epidural anesthesia?

A

Onset: 15 to 30 minutes

S79

82
Q

Epi 1:200,000 with ___________ offers no advantage in an epidural block.

A

Bupivacaine

S79

83
Q

Can epidural anesthesia cross the placental barrier with OB and C-section patients?

84
Q

What is the difference between SAB and epidural blocks?

A

Epidural blocks have No differential zone of SNS, sensory, and motor blockade.

S80

85
Q

What is considered an acceptable additive to both epidural and SAB to produce a synergistic effect?

A

Opioids

S80

86
Q

Clinical Scenario

87
Q

What is Tumescent?

A

Subcutaneous infiltration of large volume (5L or more)

S82

88
Q

What makes up the tumescent solution?

A
  • Diluted Lidocaine (0.05% to 0.1%)
  • Epinephrine 1:100,000

S82

89
Q

What causes the tumescent effect?

A

The taunt stretching of overlying blanched skin d/t large volume → Tumescent Effect

Fat can be aspirated without blood loss and provide prolonged post-op analgesia.

S82

90
Q

Where is tumescent usually administered?

A
  • Thigh
  • Abdomen
  • Hips
  • Buttocks

S83

91
Q

When is the plasma peak for tumescent anesthesia?

A

12 to 14 hours s/p injection.

S84

92
Q

What is the dose for Regional Anesthesia Lidocaine with Epi?

A

7 mg/kg

S83

93
Q

Highly diluted Lidocaine with Epi Tumescent dose.

A

35 to 55 mg/kg

S83

94
Q

What is the theory with the Tissue Buffering System?

A

1 gram of SQ can absorb up to 1 mg of Lidocaine

KM (Spring 2024) Anesthesia Pharm ** (101 decks)

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