Required Reading-Drugs

Question 1

IV induction agents

Answer 1

propofol, etomidate, ketamine, thiopental

Question 2

IV opioids

Answer 2

fentanyl, morphine, hydromorphone, remifentanil

Question 3

General anesthetics will ensure that pt is _____ and ____ throughout the procedure.

Answer 3

unconscious; amnesic

Question 4

____ and ___ nerve blocks deliver drugs to precise locations along neural transmission pathways; ___ drugs are usually used.

Answer 4

Neuraxial (spinal/epidural); peripheral; local anesthetic

Question 5

Benzodiazepines have ___, ___ and ___ effects due to GABA transmission enhancement. Benefit is ______ therapy.

Answer 5

sedative; anxiolytic; amnesic; anticonvulsant

Question 6

Midazolam (Versed)–IV sedative dose ___; effects last 20-30 min due to ______

Answer 6

1-2 mg; redistribution

Question 7

Benzos do NOT provide ___ effects.

Answer 7

analgesia

Question 8

Monitored anesthesia care [MAC]/general anesthesia can be replaced by ____ to provide sedation/amnesia in OR. This is particularly useful in patients with poor _____ status who may not tolerate enough inhaled agents to be unconscious.

Answer 8

benzodiazepines; hemodynamic

Question 9

Tx for oversedation due to benzos; only lasts about ____, which is particularly a problem with long-lasting benzos (re-sedation), like ____.

Answer 9

flumazenil (Romazicon); diazepam (t1/2 about 20hrs)

Question 10

Opioids have ___ and ___ (not reliable) effects; bind receptors in ___ of brain and ___ of SC.

Answer 10

sedative; analgesic; periacqueductal gray; substantia gelatinosa

Question 11

Opioid binding R cause inhibition of _____ and ____ release.

Answer 11

ACh; substance P

Question 12

Analgesia– short-acting opioids, like ____, are used for pain control ____; long-acting opioids used for _____ pain control.

Answer 12

fentanyl; intraoperatively; postop (morphine, hydromorphone, meperidine)

Question 13

Fentanyl– rapid-acting opioid; given during ___ of anesthesia to blunt sympathetic response during ____. Neg effects: can cause ___ in high doses

Answer 13

induction; intubation; apparent chest wall rigidity (>1000mcg; may impair adequate ventilation)

Question 14

Sufentanil– rapid-acting opioid used for ____ and ____

Answer 14

induction; maintenance

Question 15

Alfentanil– ULTRA rapid-acting opioid (5-10 min); about ___ as potent as fentanyl but with ___ onset; used for ___ and ___

Answer 15

25%; fast (1-2 min); induction; maintenance

Question 16

Morphine– long-acting (peak onset 30 min) opioid; ___-soluble and can accumulate in the presence of _____, causing bradycardia and ___ release

Answer 16

lipid; renal failure; histamine; [typical dose postop 5-15mg]

Question 17

Hydromorphone– long-acting (peak 15-30min) opioid; MC used for ___ pain control

Answer 17

postop [typical dose 1-2mg]

Question 18

Meperidine–must be metabolized to normeperidine; has ___ properties (postop use); can accumulate in pts w/ ____ leading to oversedation or ___ and histamine release. Should be avoided in pts on ______.

Answer 18

anti-shivering; renal failure; seizures; type A MAOIs [serotonin-like syndrome hyperthermia, seizures, death]

Question 19

Remifentanil–ULTRA short-acting (t/12 ~___min) b/c broken down by nonspecific ____, so does not ____ in patients with renal/hepatic failure; good for short intraop cases (~2hrs)

Answer 19

4; plasma esterases; accumulate

Question 20

Accumulating opioids (___> alfentanil/sufentanil > ____) the context-sensitive half-time increases w/ long durations of administration

Answer 20

fentanyl; remifentanil

Question 21

Main adverse effect of opioids is respiratory depression due to a decrease in _____ and an increase in the _____.

Answer 21

hypoxic drive; apneic threshold [CO2 level above which patients are stimulated to breathe]

Question 22

To reverse opioids, use ____, which antagonizes ___ receptors.

Answer 22

naloxone; mu

Question 23

Methylnaltrexone, opioid antagonist like naltrexone, can block peripheral receptors located in the ____ without affecting analgesia.

Answer 23

GI tract

Question 24

Because of blunting of endocrine response, opioids can decrease ____ with minimal effects on baseline ___ status. Good for OR pt w/ ____.

Answer 24

stress response; CV; hemodynamic instability

Question 25

Any IV med that causes a patient to be unconscious is considered an _____; benzos and opioids are MC used together

Answer 25

induction agent

Question 26

Propofol– enhances ____ receptor; IV rapid-onset (t/12 ___ min) and short DOA due to rapid ___ metabolism and excretion by ___.

Answer 26

GABA-A; 2-8; hepatic; kidneys [**few pharmacokinetic changes w/ pts w/ liver or renal dz!!]

Question 27

Propofol is ___philic and provides ___ for gen anesthesia. A common SE is __ after an induction dose.

Answer 27

lipo; sedation; apnea

Question 28

Propofol is a potent __ and __ depressant and therefore is avoided when pts need to maintain spontaneous ventilation, are hypotensive or unable to sustain ____ stability.

Answer 28

CV; respiratory; hemodynamic

Question 29

Favorable SEs of propofol include anti___ and anti___ properties. MC SEs is pain on injection, for which ___ is added.

Answer 29

pruritic; emetic; lidocaine

Question 30

Thiopental– __ drug class; rapid onset; CV and respiratory depression; most use for effect of prolonged _____

Answer 30

barbiturate; cognitive disarray

Question 31

Thiopental is used in ____ sx cases because it is cerebro-protective

Answer 31

brain

Question 32

Main problem with thiopental is that because it is ____, it can precipitate and occlude catheters if mixed with _____.

Answer 32

alkaline; paralytic agents (acidic)

Question 33

Thiopental induces the enzyme _____ and therefore is contraindicated in pt w/ inducible porphyrias

Answer 33

ALAS [RLS in prophyrin synthesis]

Question 34

Thiopental may result in delayed effects due to high ____ and low _____

Answer 34

protein binding; hepatic excretion ratio

Question 35

Etomidate– ___ drug class [inc GABA transmission]; unlike propofol/thiopental, has MINIMAL ___ and ____.

Answer 35

imidazole; CV depression; respiratory depression [Therefore it is safer in hemodynamically unstable pts]

Question 36

Etomidate is used in these three patient populations:

Answer 36

(1) elderly (2) trauma patients (3) severely volume depleted/on vasopressors

Question 37

After a single bolus, the clinical effect of etomidate is terminated by ____ and rapid _____.

Answer 37

redistribution; hepatic metabolism

Question 38

A SE of transient _____ after etomidate is due to enzyme inhibition; therefore try not to use with ___ drugs or those with ______. MC SE is myoclonus and postop ___ and ___.

Answer 38

adrenal suppression; steroid; adrenal insufficiency; nausea; vomiting

Question 39

Ketamine– acts as antagonist at ____ R; SEs are ____, like those due to PCP [related], ___ and increase in ICP

Answer 39

NMDA; hallucinatory; salivation

Question 40

Ketamine is the ONLY ___ stimulant because it inhibits NE reuptake and has minimal effect on respiratory drive; also a potent ___ and ____

Answer 40

CV; analgesic; bronchodilator

Question 41

Ketamine is used in these two patient populations

Answer 41

(1) trauma [sedation, analgesia, amnesia, CV support] (2) pediatrics [hallucinations not as scary]

Question 42

Ketamine is AVOIDED in these two pt populations

Answer 42

(1) cardiac issues [arrhythmias, HTN] (2) where pt is going to emerge from anesthesia soon after admin [short cases]

Question 43

NMBs are used to facilitate ____. Adequacy of relaxation can be determined by use of a _____.

Answer 43

intubation; nerve stimulator

Question 44

Succinylcholine– depolarizing NMBs; prevents junctional ____ b/c drug isn’t hydrolyzed by true AChE; used almost exclusively for ______

Answer 44

repolarization; intubation

Question 45

Succinylcholine has quick onset ___ seconds and duration ___ min; if repeated doses are administered, ___ blockade may occur leading to a slow recovery

Answer 45

30-45; five; phase II [prolonged end-plate depol leads to conformational changes w/in AChR]

Question 46

___ is the enzyme that breaks down succinylcholine; some pple have a partial/total deficiency and thus can experience prolonged paralysis: ___ min for hetero and ___ hrs for homozygotes

Answer 46

Pseudocholinesterase; 20-30; 6-8

Question 47

SE of succinylcholine is elevation in ____ after admin. Must be used in caution with ___ patients or those with ___ or ___ injury.

Answer 47

potassium; burn; denervation; muscle

Question 48

SEs of note are succinylcholine are bradycardia and ______

Answer 48

malignant hyperthermia

Question 49

Nondepolarizing NMBs are AChR antagonists that inhibit junctional _____; they are divided into benzylisoquinoliniums (______) and steroidals (______, _____ and ______)

Answer 49

depolarization; cisatracurium; rocuronium, vecuronium, pancuronium

Question 50

Onset time and duration of action of nondepol NMBs are: ____ > _____ > _____ > _____

Answer 50

pancuronium; cisatracurium; vecuronium; rocuronium

Question 51

___ is simultaneously administered with neostigmine to prevent muscarinic overactivity [bradycardia, asytole, bronchospasm] when reversing NMB agents.

Answer 51

Glycopyrrolate [also atropine]

Question 52

____ is a NMB is that is degraded in the plasma and is used when there is severe renal/hepatic dysfunction.

Answer 52

Cisatracurium

Question 53

Cholinergic crisis post-tx neostigmine consists of these symptoms:

Answer 53

bradycardia, bronchospasm, emesis, miosis, muscle weakness

Question 54

Neostigmine and glycopyrrolate [paired] have a ___ onset and ___ duration compared to edrophonium and atropine [paired]

Answer 54

slower; longer

Question 55

Central anticholinergic syndrome is due to atropine [unlike ___] overdose because it crosses the _____. Symptoms include ____. Treat with physostigmine.

Answer 55

glycopyrrolate; BBB; delirium, excitation, fever, flushing, tachycardia

Question 56

Complete anesthesia includes ___, ____ and ____.

Answer 56

hypnosis [sedative], analgesia [opioids], muscle relaxation

Question 57

Which opioids would be best to use for 1.5hr case? Postop?

Answer 57

sufentanil, alfentanil, remifentanil (need relatively flat context-sensitive half time curves); fentanyl, morphine, hydromorphone

Question 58

You conduct emergence from anesthesia via ____, ____ and possibly ____ if needed

Answer 58

reverse NMB; discontinue opioid infusion; small dose longer-acting analgesia [esp if using remifentanil]