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Pharmacology > Propofol, Etomidate, Ketamine > Flashcards

Propofol, Etomidate, Ketamine Flashcards

1
Q

Propofol is aqueous emulsion of what

A

10% soybean oil/propofol mix in water

  1. 25% glycerol
  2. 2% egg phosphatide
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2
Q

More likely to have allergic reaction to propofol if prior reaction to what

A

Purfumes or detergents

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3
Q

Effect of propofol post op in heart patients

A

Blunts post-op tachycardia and hypertension

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4
Q

Propofol provides what 3

A
  • control of stress response (decrease serum cortisol levels)
  • anti-convulsant properties
  • amnesia properties
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5
Q

Does propofol have analgesic properties

A

No

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6
Q

Induction drug of choice for rapid wake up

A

Propofol

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7
Q

Is propofol a trigger of MH?

A

No

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8
Q

Induction dose of propofol

A

1-2.5mg/kg

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9
Q

Pediatric dose of propofol

A

2.5-3.5 mg/kg

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10
Q

Why do children need greater induction dose of propofol?

A

Larger central distribution volumes and greater clearance rates

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11
Q

Elderly induction dose of propofol?

Why?

A

25-50% less than normal

Smaller central distribution volumes and smaller clearance rates

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12
Q

To avoid adverse CV effects of propofol induction dose do what

A

Give incrementally

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13
Q

Concious sedation dose of propofol

A

25-300 mcg/kg/min

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14
Q

Cardiac post op dose of propofol

A

25-75 mcg/kg/min

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15
Q

Clearance of propofol from plasma from what?

A

Hepatic and extra-hepatic metabolism

Tissue uptake by VRG

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16
Q

Hepatic metabolism of propofol is

How much excreted unchanged?

A

Rapid and extensive

0.3% excreted unchanged

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17
Q

Propofol metabolites

A

Pharmacologically inactive

Water soluble Sulfate & glucuronic acid compounds excreted in urine

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18
Q

Elimination 1/2 time for propofol

A

0.5-1.5 hours

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19
Q

Does length of infusion of propofol effect context sensitive 1/2 time if appropriately dosed

A

No

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20
Q

4 advantages of propofol

A

Easy titration
Prompt recovery
Less residual sedation
Low incidence of N&V

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21
Q

Concious sedation dose provides what?

A

Minimal analgesia effects

Excellent amnesia effects

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22
Q

Is elimination of propofol impaired with cirrhosis or ESRD?

A

No impairment

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23
Q

In pt over 60 there is

A

Impairment of elimination

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24
Q

Propofol and fetal circulation

A

Crosses placenta but rapidly cleared

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25
Q

Propofol interacts with what receptors

A

GABA

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26
Q

GABA receptor activation results in what (3)

A
  1. Increased chloride conduction
  2. Hyperpolarization of post-synaptic cell membranes
  3. Inhibition of post-synaptic neurons
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27
Q

Sub-hypnotic dose for PONV in PACU

A

10-15mg

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28
Q

To tx N&V does

A

10mg bolus followed by 10 mcg/kg/min

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29
Q

Which drug has most rapid and complete awakening of any induction drug?

A

Propofol

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30
Q

Does propofol have to be given as induction drug for PONV prevention

A

No. Can give at any time during anesthetic

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31
Q

Propofol effect on CNS

A

Depresses CNS structures

Direct depressant on vomiting center

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32
Q

Propofol anti-convulsants properties due to _____

A

GABA mediated pre and post synaptic inhibition

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33
Q

Propofol effect on intraoccular pressure

A

Lowers beginning with induction and lasting through intubation

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34
Q

Propofol has anti-oxidant properties resulting in what

A

Neuro-protective qualities

Protective qualities against lung injury

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35
Q

Propofol and Parkinson’s tremors?

effect on anesthetic

A

May abolish tremors

Use cautiously in stereotactic neuro tremor ablation surgeries

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36
Q

Propofol in doses of what decrease seizure duration 35-45% in ECT patients

A

Greater than 1 mg/kg decrease seizure duration

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37
Q

Profound and CMRO2 requirements, CBF, ICP

A

Decreases all

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38
Q

Propofol and EP monitoring

A

Doesn’t effect EP monitoring

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39
Q

Propofol produces EEG cortical changes similar to thiopental including what

A

Burst suppression in high doses

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40
Q

__________ treats pruitis of neuroaxial opioids

A

Propofol

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41
Q

Propofol effect on BP and inotropy

A

Decreases BP inhibits sympathetic vasoconstrictor nerve activity

Negative inotropic effect by decreasing intracellular Calcium levels

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42
Q

Hypotensive effects of propofol are worsened in what 4 patient types

A

Hypovolemia

Elderly

Depressed LV function

Dehydration

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43
Q

Does HR change with propofol?

A

No changes to heart conduction system

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44
Q

Propofol causes what effect on ventilation

A

Dose dependent ventilatory depression

Apnea in 25-35% of inductions

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45
Q

Propofol on respiratory volumes

A

Decrease RR and TV

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46
Q

Propofol and ventilatory response to CO2 and arterial hypoxemia

A

Response is blunted

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47
Q

Does propofol produce bronchodilation?

A

YES

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48
Q

Prolonged propofol infusions may cause green urine due to what

A

Excreted phenols and cloudy urine from uric acid excretion

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49
Q

Does propofol adversely affect liver or kidney?

A

No

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50
Q

Propofol supports growth of what 2 organisms

A

E. Coil

Pseudomonas

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51
Q

Dispose of propofol within __________ of drawing it up

A

4 hours

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52
Q

Most common adverse effect with propofol

A

Pain on injection site

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53
Q

Etomidate is water soluble at what pH

A

Acidic pH

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54
Q

Etomidate is lipid soluble at what pH

A

Physiologic pH

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55
Q

Profound reduces ______ more than _______

A

SNS more than PNS

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56
Q

The first single enantiomer general anesthetic to be used clinically

A

Etomidate

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57
Q

Standard dose of etomidate

A

0.2-0.4 mg/kg

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58
Q

Etomidate concentration

A

2mg/ml

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59
Q

Etomidate VD is large due to what

A

Large tissue uptake

60
Q

At standard doses anesthesia is induced for how long

A

5-10 minutes

61
Q

1/2 of etomidate is metabolized in about _____ minutes

A

75 minutes

62
Q

Etomidate is metabolized by what 2

A

Hepatic and plasma esterases

63
Q

Protein binding of etomidate

A

76%

64
Q

Peak brain levels of etomidate occur within

A

1 minute of IV administration

65
Q

Prompt awakening with etomidate due to ______

A

Redistribution

66
Q

MOA of etomidate

A

Enhancement of GABA

67
Q

Frequent involuntary myoicolinc movements noted with etomidate due to what

Blunted by what

A

Imbalance of thalamocortical tract

blunted by opioids

68
Q

Does etomidate have any analgesic properties

A

No

69
Q

Etomidate and SSEPs

A

Augments amplitude of SSEPs improving monitoring

70
Q

Can etomidate terminate status epilepticus

A

Yes

71
Q

Etomidate reduces CMRO2 by what

A

Potent direct Cerebral vasoconstrictor

72
Q

Etomidate and EEG

A

Greater frequency of excitatory spikes

73
Q

Etomidate and epilepsy patients

A

Use with caution

74
Q

Do decrease transient skeletal muscle movements

A

Give 0.1mg fentanyl immediately before induction

75
Q

Drug of choice for IV induction of anesthesia with unstable CV system

A

Etomidate

76
Q

CV stability with etomidate at what dose?

A

0.3 mg/kg

77
Q

BP may drop 15% with etomidate 0.3mg/kg due to what

A

Decreased SVR

78
Q

What is a useful induction agent when restoration of spontaneous ventilation is desirable?

A

Etomidate

79
Q

Etomidate and ventilation volumes

A

Decreased TV offset by increased RR

80
Q

3 adverse pulmonary effects of etomidate

A

Laryngospasm
Hiccups
Snoring

81
Q

Etomidate metabolism

A

Hepatic and plasma esterases

82
Q

____% of etomidate bile excretion

A

15

83
Q

In pt with cirrhosis and esophageal varies, elimination 1/2 life and VD is

A

Doubled

84
Q

_____% etomidate excreted in urine

A

85%

85
Q

Incidence of PONV higher than propofol

A

Etomidate

86
Q

Etomidate causes transient suppression of _________

A

Adrenocortical function

87
Q

Adenocorticoid suppression with etomidate is desirable for what pt population?

A

Desired “stress free” anesthesia

88
Q

Adrenocorticoid suppression is bad in what patient population?

A

Those needing preserved cortisol response (sepsis, bleeding)

89
Q

Do Etomidate inductions significantly alter dosage requirements of NM blockers

A

No

90
Q

Does etomidate cause pain with IV injection?

A

YES. Can be worse than propofol

91
Q

Etomidate is relatively contraindicated in what pt population?

A
  • PONV
  • sepsis
  • adrenocortical suppression
  • epilepsy
  • pregnancy
  • infants
92
Q

Etomidate is not used as much as propofol because of

A

Frequent involuntary myoclonic movements (shake and bake)

93
Q

Drug developed as derivative of PCP

A

Ketamine

94
Q

Is ketamine racemic mixture

A

Yes

95
Q

Anesthesia induction dose of ketamine.

IV

IM

A

IV- 1-2 mg/kg

IM 4-8mg/kg

96
Q

Subanesthetic yet analgesic dose of ketamine

A

0.2mg/kg

97
Q

What aids in ketamine delivery to brain

A

Increases in cerebral blood flow

98
Q

High hepatic clearance and large Vd result in elimination 1/2 time of _____ with ketamine

A

2-3 hours

99
Q

Ketamine metabolism

A

Metabolized by hepatic microsomes enzymes (cytochrome P450) to form normketamine

100
Q

Normketamine is ______ as potent as ketamine

A

20-33%

101
Q

Rapid onset and short duration of action with ketamine is due to

A

High lipid solubility

102
Q

Peak plasma concentration of ketamine occurs within _____ of IV doses

A

1 minute

103
Q

Does 1 cc fentanyl have a cardiovascular effect ?

A

No

104
Q

Is ketamine significantly bound to plasma proteins

A

No

105
Q

Extreme lipid solubility of ketamine makes ____________ easier

A

Crossing of BBB

106
Q

What produces dissociative anesthesia

A

Ketamine

107
Q

Loss of conciousness occurs within _________ after IV admin of ketamine.

Conciousness returns in ______

Full orientation in ______

A

LOC- 30-60 seconds

Return- 10-20 minutes

Full orientation- 60-90 minutes

108
Q

Main receptor ketamine works on

A

NMDA

109
Q

Analgesia with ketamine is greater with ______ pain over ______ pain

A

Somatic pain > visceral pain

110
Q

Analgesia with ketamine mediated through

A

Thalamus and limbic systems

111
Q

Ketamine analgesic actions involve

A

Descending inhibitory monoaminergic pain pathways

112
Q

Cheif metabolite of etomidate is

A

Pharmacologically inactive

113
Q

Ketamine and anicholinergic actions result in

A

Bronchodilation

114
Q

________ and ______ suggest antagonistic muscarinic receptor action with ketamine

A

Sympathomimetic functions and emergence delirium

115
Q

Visual, auditory, proprioceptive, confusional hallucinations, morbid dreams, and cortical blindness with ketamine due to

A

Depression of inferior colliculus and medial geniculate nucleus

116
Q

Incidence of emergence delirium with ketamine

Increased with :

Decreased with:

A

5-30%

Increased with >15yo, women, doses > 2mg/kg, psych illness hx

Lower with- repeated dosing, benzos 5 minute before induction

117
Q

Etomidate and endocrine implications for infection

A

11 beta hydroxylase inhibition for 4-8 hours after induction

May increase infection rate

118
Q

To reduce emergence delirium with ketamine

A

Give with propofol

119
Q

Does ketamine change seizure threshold?

A

No

120
Q

SSEPs and ketamine

A

Increased amplitude of SSEPs but less than etomidate

121
Q

Sympathomimetic function associated with ketamine has what effect on heart

Anesthesia implications

A

Increases myocardial O2 needs and reduces diastolic filling of corona rise

Don’t give in pt with CAD

122
Q

1 mechanism for ketamine CV effects

A

Greater SNS outflow

123
Q

Increased plasma concentrations of epi and NE with ketamine occur within ______ and return to normal in ______

A

W/i 2 minutes

Normal in 15 minutes

124
Q

What blunts the induced CV stimulation with ketamine

A

Inhalation agents and benzos

125
Q

Ketamine CV effects

A

Increased systemic and pulmonary BP

Increased HR

Increased CO

Greater myocardial oxygen needs

126
Q

Ketamine is useful for asthmatic induction due to ______

A

Bronchodilation function

127
Q

To decrease salivary secretion induced laryngospasm and coughing with ketamine

A

Give glycopyrolate

128
Q

Why not give atropine or scopolamine for salivary secretions with ketamine?

A

Bc cross BBB and worsen emergence delirium

129
Q

Ketamine and ventilation

A

Does not significantly depress ventilation

130
Q

Ketamine and pulmonary HTN?

A

Don’t give in pt with pulmonary HTN

131
Q

Ketamine and bronchospasm

A

As effective as volatile anesthesia to prevent bronchospasm

132
Q

Ketamine and upper airway reflexes and muscle tone

A

Maintained

133
Q

Ketamine is primarily metabolized

A

Hepatic metabolism

134
Q

Chronic ketamine use effects

A

Stimulates metabolic enzyme activity.

Tolerance consistent with addiction potential

135
Q

Long term ketamine use results in inflammation and irritation of

A
  • biliary tract resulting in cholestatic liver injury

- urinary bladder and urethra

136
Q

Ketamine and GI

A

Well absorbed by GI tract

137
Q

Ketamine and Succinylcholine

A

Enhances phase 1 and phase 2 block from succ

138
Q

Pain on injection with ketamine?

A

None

139
Q

Is there histamine release or allergic rx with ketamine

A

No

140
Q

Ketamine and MAC

A

Decreases MAC

141
Q

Ketamine and inotropic support requirements

A

Reduces inotropic support requirements

142
Q

Epidural/intrathecal ketamine

A

Provide analgesia without risk of ventilatory depression

143
Q

Which induction drug worsens elevated ICP r/t increase in CBF?

A

Ketamine

144
Q

Ketamine and MH patients

A

Ok with MH patients

145
Q

Ketamine acts on what receptor resulting in drooling

A

Muscarinic

146
Q

Contraindication for ketamine

A

Systemic HTN

147
Q

Ketamine partially antagonized by

A

Phyostigmine (antilerium)

Pharmacology (6 decks)

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