Test 2 Study Guide Flashcards
What is the best method to avoid perioperative heat loss?
Forced air warming
What mechanism facilitates heat loss through air currents?
CONVECTION
Evaporative heat loss results from
fluid loss through the skin and respiratory system
Conductive heat loss occurs when
direct contact between cold and warm objects.
Radiation involves the
transfer of heat from infrared rays.
Convective heat loss requires
currents and is dependent on thermal gradients.
Phase I
To avoid the initial drop in body temperature pre-warm the patient with aforced-air warming blanket.
Phase II → To avoid heat loss during
Phase II, all other warming methods in combinationare use
What mechanism results in the greatest amount of heat loss in the operating room?
RADIATION (60%),
When is body temperature loss the greatest?
The greatest amount of heat loss occurs during the 1st hour in the operating room (0.5-1.5C).
Patients lose most heat through
radiation from their exposed skin to the surrounding cold environment.Thereafter temperature decline is gradual and then plateaus
Most critical factor for heat loss during anesthesia and surgery ?
Operating room temperature
Most body heat is lost by 2 processes
RADIATION and CONVECTIOn from the skin and surgical incisions
One of the best ways to minimize body heat loss during anesthesia and surgery ?
Increase OR room temperature
Padding the patient everywhere prevents heat loss by what routes?
Padding serves as insulation and prevents heat loss by convection and radiation
Responsible for the metabolism of the Largest portion of drugs in the body
CYP450
CYP 3A4 comprises
40-50% of the system’s metabolizing capabilities
The hepatic microsomal enzymes are present with the greatest degree of metabolism occuring in the
HEPATIC SMOOTH ER, GI, kidneys, adrenal cortex
4 medications all metabolizes by CYP450
Phenytoin, ethanol, barbiturates and Ketamine,
The hepatic microsomal enzymes of the p450 system are generally confined to the
Smooth Endoplasmic reticulum
Where is the primary location of hepatic microsomal enzymes?
Hepatic smooth endoplasmic reticulum
The only process that does not involve the cytochrome P450 pathway is
HYDROLYSIS
Common substrate for phase II conjugation reactions:
Glucuronic acid Glycine Acetic acid Sulfuric acid Methyl group
CYP2D6 substrate ->
Codeine ; Oxycodone ; Hydrocodone
Inducers of CYP2D6 →
Disulfiram
Inhibitors of CYP2D6 →
SSRIs, Isoniazid, Quinidine
Examples of Enzymes inducers (RPPCSC)
Rifampin Phenytoin Phenobarbital (barbiturates) Carbamezepine Smoking tobacco Consuming alcohol
Examples of Enzyme inhibitors (CAGEKOI)
Cimetidine Amiodarone Grapefruit Juice Erythromycin Ketoconazole Omeprazole Isoniazid
CYP1A2 inhibitors →
Erythromycin; Ciprofloxacin
3 drugs that under perfusion dependent hepatic elimination ?
Propofol
Fentanyl
Lidocaine
The rule of thumb is that steady state will be achieved after
5 half lives
How many half lives to eliminate 97 % of the drugs?
5
The context sensitive half time of fentanyl ?
longs 240mns
Predicts the time it takes for 50% of a drug to be eliminated from the central compartment when a continuous infusion is discontinued?
Context sensitive half time
The plasma half-life of a drug is inversely proportional to its
RATE OF CLEARANCE
Hepatic enzyme induction will result in a reduction in the drugs “
HALF TIME or LIFE”
Elimination half-life is the
time taken for a drug to lose half of its pharmacologic or physiologic activity.
Formula of T ½ is :
T ½ = Vd / Cl
Half time of elimination is greater if Vd is ____and clearance is
volume of distribution is LARGE and Clearnce is SMALL
Elimination half time and volume of distribution →
Directly proportional
Elimination half time and clearance →
Inversely proportional
How does the elimination half-time of remifentanil differ from alfentanil?
Elimination half-time is shorter or remifentanil
Half-life (hours) =
0.693 x (Volume of distribution (L) / Clearance (L/hr))
What causes an increased end-tidal carbon dioxide?
CNS depression
INCREASES IN METABOLIC RATE (increased VO2)
Increases CO2 production
Hypotension leads to
CO2 production
Things that causes an increase in CO2
MASTT FPC
Malignant Hyperthermia Anxiety Seizures/ SEPSIS Thyrotoxicosis Tourniquet and vascular clamps removal Fever/ Sodium bicarbonate administration Pain CO2 insufflation with laparoscopic surgeries
Main mechanism of Increased ETCO2?
Increase alveolar ventilation
Elevated ETCO2 with normal plateau?
Make sure you look at the baseline and that it returns to zero. Its not rebreathing. Occurs with increased production of CO2 or DECREASED ALVEOLAR VENTILATION
Capnography measures
ETCO2 concentration over time.
Capnography measures 3 main things?
Assessment of metabolism
Circulation
Ventilation
CO2 diffuses airway then from the tissues on, what happen?
from the tissue and enters the venous circulation, From here, the CO determines the rate of transfer towards the lungs. In the lungs, CO2 follows a concentration gradient as it diffuses across the alveolar capillary membrane. Once the CO2 in the alveolus, ventilation is the process by which CO2 is removed from the body
What point in the CO2 waverform is ETCO2 measure?
Point D
Normal ETCO2
35-40 mmHg
ETCO2 Waveform: An increase alpha angle means
EXPIRATORY AIRFLOW OBSTRUCTION such as COPD, bronchospasm or a KINKED ETT TUBE.
Widened beta angle on CO2 waveform means
Incompentent unidirectional valve
Identify caused of the abnormal waveform if there is a CARDIAC OSCILLATION?
Heart beating against the lungs
Leak in sample time CO2 waveform?
The beginning of the plateau is low, because dilution of alveolar gas at atmospheric air is aspirated into the sample line. NOT SEEN WITH SPONTANEOUS VENTILATION.
2 Methods of CO2 analysis
Mainstream (in line)
Sidestream (diverting )
Low ETCO2 indicates
Hyperventilation
Increased alveolar dead space
Decrease CO2 production
Alpha angle is where?
between the first expiration upstroke and the plateau line
Beta angle is
REBREATHING reading
Baseline not returning to zero is
REBREATHING
What CO2 analysis method has a faster response time-
Mainstream , does not require a water trap or pumping mechanism
Capnogram Phases I.
Dead space gas exhaled
Capnogram Phases II.
Transition between airway and alveolar gas
Capnogram Phases III.
Alveolar plateau
Capnogram Phase IV
Inspiration
What CO2 analysis methods is the device attached to the ETT?
-Mainstream (in line)
Impaired RELAXATION is what phase of diastolic dysfunction
Grade I
Phase I of diastolic dysfunction is
Impaired relaxation
Phase II of diastolic dysfunction
Pseudonormal filling
Phase III of diastolic dysfunction
Restrictive filling
Phase III of diastolic dysfunction
Reversible Restrictive filling
Phase IV of diastolic dysfunction
Irreversible Restrictive filling
The early manifestation of diastolic dysfunction is characterized by an
impaired relaxation,
This stage of disease is known as grade I diastolic dysfunction
inability of the LV to fill adequately during the rapid filling phase. A compensatory increase in filling occurs with atrial contraction.
In summary, in grades II and III of diastolic dysfunction, there is a decrease in
LV compliance ensues.
Compliance is defined as a
change of volume with respect to a change in pressure. decrease in LV compliance will lead to a disproportionate increase in LV pressures and, ultimately, LA pressures.
Grade I : the TMF curve of an individual with abnormal relaxation is represented by a (LeHapDT)
low E, high A, and prolonged DT
Grade I diastolic dysfunction, as the LV is
incompletely relaxed when early ventricular filling occurs, t
The pressure gradient, and thus E wave velocity, is less than normal.
In Grade I, E wave velocity is
less than normal
In Grade I, The delayed relaxation prolongs LV filling late into diastole, and therefore the DT is
prolonged.
Because the DT is prolonged in grade I, A compensatory increase in
TMF during atrial contraction, due to the higher residual atrial preload, generates a high A wave velocity
A wave in Grade I is
High
Progression of diastolic disease leads to grade II diastolic dysfunction, which is marked by
decreases in LV compliance
For Grade II, LA pressure rises as a compensatory mechanism to normalize the pressure gradient across the MV. In this scenario, the
TMF velocities resemble the normal curve; thus, this
stage is known as pseudonorma
Grade III diastolic dysfunction, known as the
Restrictive phase,
Grade III diastolic dysfunction, known as the restrictive phase is characterized by a
significantly decreased LV compliance
In Grade III, The high LA–LV pressure gradient produces a
fast acceleration of blood flow in the LV.
A high E velocity on the TMF curve is representative for
grade III diastolic dysfunction
What represent Grade III diastolic dysfunction?
A high E velocity on the TMF curve
In Grade III diastolic dysfunction: LV pressure and effect on DT?
LV pressure increases rapidly during filling because of the increased LV stiffness resulting in a short DT. The forward filling velocity at atrial contraction is low (small A wave) because of the decreased compliance
Cardiac tumors either can originate
from the heart or are metastases from other sites.
Cardiac masses can
embolize, cause arrhythmias, or cause heart failure.
The most common primary tumor of cardiac is
myxoma,
Myxoma most common location
most frequently at the interatrial septum
The potential of myxomas to
obstruct the inflow or outflow region of a ventricle is
demonstrated with Doppler echocardiography.
The 2nd most common cardiac tumor next most frequent tumor
is . (Fig. 27-42C).
fibroma of the ventricular wall.
Fibromas are usually
calcified and can decrease the ventricular volume
Renal cell tumors often
extend into the inferior vena cava and right atrium
Should be differentiated from tumors.
Pacemaker wires, thrombus, and normal anatomic structures that mimic the appearance of
pathology (Eustachian valve, crista terminalis, Chiari network, or “Coumadin”ridge)
During exposure of the aneurysm, burst-suppression on the EEG may be desired to
decrease the impending ischemic burden on the brain from temporary occlusion of large cerebral vessels
Burst-suppression can be accomplished with .
propofol administered as a 1- to 2-mg/kg bolus followed
by infusion of 100 to 150 μg/kg/min. Additional vasopressor may be required during this time to maintain CPP.
→ Does not produce burst suppresion
Benzodiazepines
Electroencephalogram (EEG) burst suppression is characterized by
periods of isoelectric EEG punctuated by “bursts” of EEG activity.
Electroencephalogram (EEG) burst suppression is characterized by
periods of isoelectric EEG punctuated by “bursts” of EEG activity.
Burst suppresion is caused by
BARBITURATES and PROPOFOL
Burst suppression occurs at close to
to 1.5 MAC
Define burst suppression
The “burst” is high-frequency activity and the “suppression” is O.S· to several-second periods of isoelectric activity
At greater than 2 MAC, all of the potent agents can produce.
burst suppression or electrical silence
These are important factors to remember because EEG changes during administration of general anesthesia can also be caused by
hypoxia, hypercarbia, and hypothermia.
Burst suppression can be done by
It can be attained at concentrations of propofol (8 μg/mL) that are significantly higher than the blood concentrations needed to reach the initial stages of general anesthesia (3 μg/mL). A further increase in propofol concentration will lead to an isoelectric EEG pattern.
Unlike benzodiazepines, etomidate can
achieve burst suppression with a concomitant
decrease in ICP
However, despite its neurodepressant properties at high
doses, etomidate is often associated with
epileptogenic activity (excitatory spikes) on EEG.
Thiopental induced
burst suppression and isoelectric EEG prior to potential focal ischemic insult
TIVA is associated with
smooth induction and rapid emergence with less postoperative nausea and vomiting.
is emerging as a standard method to administer safe anesthesia in neurosurgical patients.
.
Administration of TIVA using target-controlled infusion technique
What has become very popular due to their favorable pharmacokinetic and pharmacodynamic properties for neurosurgery case?
The propofol–remifentanil combination has
Attractive for ICU sedation in neurosurgery, as patients can participate in neurologic examinations while receiving this medication
Dexmedetomidine
The BIS uses a proprietary algorithm that processes the in near real time and computes an index between that
0 and 100
EEG indicates the patient’s
level of consciousness.
EEG; BIS A value of 100 corresponds to ____and a value of 0 is ____
being completely awake, whereas 0 corresponds to a profound state of coma or unconsciousness that is reflected by an isoelectric or flat EEG.
A patient is considered to be appropriately anesthetized when the BIS value is between
40 and 60
Since the bispectral index (BIS) is based upon the hypnotic action of agents, the BIS is not affected by
opioids or analgesics.
Nitrous oxide alone on BIS
will have no effect on BIS
At BIS values lower than 40,
cortical suppression becomes discernible in a raw electroencephalogram as a burst suppression pattern
BIS values o 65-85 have been recommended or sedation, whereas values o
For sedation
BIS valueshave been recommended for general anesthesia.
40-65
BIS and Ketamine
has minimal effect on BIS, and may slightly increase BIS transiently
Common second-messenger molecules include
Identify the cyclic nucleotide second messenger that mediates the cellular actions of natriuretic peptide?
cyclic adenosine 3′-5′-monophosphate (cAMP), inositol 1,4,5-trisphosphate (IP 3), 1,2-diacylglycerol (DAG), and calcium ions (Ca 2+).
lpratropium (Atrovent) works by blocking the production of what second messenger?
Blockade of the muscarinic receptor by ipratropium will lead to a decrease in inositol triphosphate (IPJ). Notes: In the absence of IP3, what happens to calcium? less calcium is released from intracellular vesicles, so smooth muscle tone is decreased.
By what receptor and second messenger system does glucagon exert its positive inotropic and chronotropic effects?
Glucagon acts through its own G-protein coupled receptor (GPCR) and generation of cyclic adenosine monophosphate (cAMP). In other words, glucagon binds to glucagon receptors to promote the formation of cAMP.
Cyclic GMP, a second messenger, action?
relaxes vascular smooth muscle, thereby promoting vasodilation and a decrease in blood pressure.
Certain G-protein subunits
can stimulate or inhibit membrane-bound adenylate cyclase, which catalyzes cAMP formation.
Cyclic guanosine monophosphate (cGMP) mediates the
cellular actions of natriuretic peptides.
Nitroprusside and nitroglycerin donate nitric oxide (NO). Nitric oxide (NO) activates the enzyme soluble
guanylate cyclase, which increases the production of cyclic guanosine monophosphate (cGMP).
Within the VSMCs, NO reacts with the heme moiety in soluble guanylate cyclase, leading to a greater than
100-fold increase in the conversion of guanosine triphosphate to the secondary messenger
cyclic guanosine monophosphate [cGMP])
cGMP associated with this medication
Sodium Nitroprusside
The b1-adrenergic receptor located on the cardiac sarcolemma is coupled to
adenyl cyclase via a G protein.
When activated, adenyl cyclase converts
adenosine triphosphate (ATP) to cyclic adenosine monophosphate (cAMP), a secondary intracellular messenger, that stimulates protein kinase A to phosphorylate membrane calcium channels, leading to an increase in cytoplasmic Calcium
For CCB , The Ca21 functions as a s
econdary messenger—its divalent charge is sufficient to produce conformational change in a number
of cytoplasmic proteins, such as actin-myosin.
Name four second messengers for mediating intracellular hormonal functions besides cAMP.
Calcium ions, calmodulin, cyclic guanosine monophosphate (cGMP), and inositol triphosphate ([P3).
opioids action can be reversed by direct antagonism with
naloxone,inhibitors of cyclooxygenase, histamine antagonist
A direct acting antagonist has
affinity for a receptor but lacks efficacy
Silent antagonists are competitive receptor antagonists that have
zero intrinsic activity for activating a receptor.
What local anesthetics, those with high pKas or those with low pKas, are most ionized at physiological pH (pH=7.4)? ,
Those local anesthetics with the highest pKas are most ionized at pHz:7.4. Procaine (pKa = 8.9, 97% ionized), chloroprocaine (pKa = 8.7, 95% ionized), and tetracaine (pKa = 8.5, 93% ionized) are most ionized at pH =7.4.
The speed of onset of a local anesthetic is determined by its
degree of ionization which, in turn, is determined by its pKa.
The greater the degree of ionization of a local anesthetic {the higher the pKa),
the slower the speed of onset.
Bupivacaine has a slower onset than
lidocaine because it is more ionized (has a higher pKa of 8.1) than lidocaine (pKa - 7.9) at physiological pH
Approximately what % of CO delivered to the vessel-rich organs, although they constitute ______-%only body mass.
75% of resting cardiac output; 10% of total
Muscle group % of CO
16% CO
Adipose tissue Bone , ligament % CO
6% of CO
Phase II of drug metabolism is CONJUGATION
Compound can be readily eliminated from the body
What is the significance of phase II reactions?
Phase II reactions couples (conjugate a parent drug) or a phase I metabolite with an endogenous substrate such as GLUCURONIC acid to form water soluble metabolites that are eliminated in urine or stoool
Phase I metabolites may be excreted without
undergoing phase II, and a phase II reaction can precede or occur without a phase I reaction
CYP2D6 is functionally absent in 7 percent of , while deficiency is rare among
Caucasians and African Americans; Asians
At conventional doses, subjects who are poor metabolizers based upon CYP2D6 genotype will
derive no therapeutic benefit from codeine
Cytochrome P450 2C19 enzymes are involved in the metabolism of
proton pump inhibitors and antidepressants.
An example is the enzyme CYP2D6, which catalyzes the
conversion of codeine into morphine.
Patients with multiple copies of the CYP2D6 gene and who receive codeine will have
large plasma morphine concentrations with all related
beneficial and adverse side effects
This is important for drugs that rely on CYP2D6 to convert an
inactive precursor (prodrug), such as codeine, into the active component of pain therapy (for codeine this is morphine)
Poor metabolizers display incomplete analgesia. The
frequency of poor metabolizers varies by ethnicity and is reported to be
8% in whites, 2% to 7% in African Americans and 0% to 0.5% in Asian populations.
With CYP 2D6 Patients without an active gene will have no
benefit from treatment with codeine.
With CYP2D6 Dangerous circumstances may occur when a
patient is an extensive metabolizer and produces large amounts of the active component.
Loading dose is =
Vd x target concentration
The loading dose is contingent on the
volume of distribution
Maintenance doses are dependent on
plasma clearance.
The loading dose is only required for a
few drugs in certain situations while maintenance doses are required for most drugs to maintain the steady-state plasma concentration
However, from the clinical perspective, the single most important utility of Vd is calculating the
loading dose of a drug.
The most significant aspect of the metabolism of barbiturates (e.g., phenobarbital, thiopental, methohexital) is their effect on the Chronic use of
hepatic microsomal enzyme system (cytochrome P450 (CYP) enzymes).
These effects are dependent on the duration of exposure to the barbiturate. Acutely, barbiturates interact with various
CYPs and inhibit the biotransformation of other CYP substrates;
Other substrates (e.g., other drugs or endogenous substrates) can inhibit the barbiturate
metabolism.
Barbiturates will cause upregulation, or induction, of the microsomal enzymes (CYPs 1A2, 2C9, 2C19, and 3A4), increasing the
metabolism of drugs metabolized by these enzymes. This can lead to patients requiring larger dosages of medication to achieve therapeutic effect and/or increased clearance. This enzyme induction also causes barbiturate tolerance due increased barbiturate metabolism
Acute barbiturates abuse
decrease anesthetic requirements.
A phenol group substitution at position 5 of barbiturates forms phenobarbital. What clinically useful feature does the phenol substitution create
Phenobarbital has a phenol group substitution at position 5-the phenol substitution confers an anticonvulsant property to the barbiturate.
On the ECG, ST segment depression of greater
than 1 mm provides evidence of myocardial ischemia
ST segment monitoring To interpret ST segment changes properly, the
ECG must be standardized so that a 1-mV signal results in a deflection of 10mm on a standard strip monitor. Newer units continuously analyze ST segments for early detection of myocardial infarction.
ST-segment elevation
(J point
The “a” wave on the central venous pressure tracing corresponds to which on the EKG tracing?
P wave
The y-descent of the CVP waveform corresponds to the
opening of the tricuspid valve during diastole and therefore is observed immediately following the v wave on CVP and shortly after the wave on the ECG.
The a wave follows the
P wave on the ECG.
The c wave immediately follows the
start of the QRS complex on ECG.
The v wave appears
shortly after the start of the wave on the ECG.
Y descent Mechanical event vs electrical events →
RA empties through open tricuspid valve (mechanical) After T wave ends
V wave Mechanical event vs electrical events –>
Passive filling of RA (mechanical) Just after T wave begins (ventricular repolarization)
X Descent Mechanical event vs electrical events→
RA relaxation (mechanical) ST segment (Electrical event)
C wave Mechanical event vs electrical events –>
Right ventricular contraction (building of Tricuspid in RA)’->mechanical Just after the QRS complex (ventricular depolarization)
A wave Mechanical event vs electrical events →
Right atrial contraction (mechanical)
Just after the P wave (Atrial depolarization)
T wave corresponds with _____wave →
v wave
ST segment corresponds with _______→
x descent
QRS complex corresponds with —>
C wave
V wave is the →
passive filling
X descent is →
Right atrial relaxation
What three measures are taken to increase the accuracy and precision of the cardiac outputs measured by thermodilution?
Triplicate determinations are averaged to increase precision the variability of cardiac output measurements can be reduced by performing the measurement at end-inspiration or at end-expiration;
(3) ensuring that the rate of injection and volume of injectate are constant.
Factors that influence themodilution CO measurement: Underestimate CO
Injectate volume too high
Injectate solution too cold
Which situation underestimates CO obtained by the thermodilution method?
High Injectate volume
False high thermodilution cardiac output determinations occur when the injectate volume is
TOO SMALL
False low determinations occur when injectate volume is
TOO LARGE
If you inject 10 ml of cold normal saline when the cardiac output computer is set for 5 ml, will calculated cardiac output be higher or lower than actual cardiac output?
Calculated cardiac output will be lower than the true cardiac output
The area under the curve will be larger if a greater volume is injected; so cardiac output will be
falsely low
Avoid measurements of cardiac output using the thermodilution method during
electrocautery.
Right atrium:
15-22 cm (15-20)
Right ventricle:
25- 35 cm (30)
Pulmonary artery
40- 50 cm (40)
The distance from SKIN to the junction of the VC and RA is
15 cm
Insertion site to VC and RA junction: Left IJ insertion site.
20 cm
Pulmonary wedge distance
45- 50 cm (45)
Vena Cava and R atrial Junction –> catheter tip:
PA 40cm
Provides the shortest distance to the junction of the vena cava and the right atrium (approximately 10 cm) compared to other anatomic sites such as the he
The subclavian vein
Distance to the junction of the vena cava and the
internal jugular veins ; femoral vein and right basilica vein
(15–20 cm); 40 ; 40
O2-Hb Curve Shifts Right Shift means
lower affinity for O2 = increased unloading at tissues)
O2 dissociation curve shifts to the RIGHT with
Acidosis • Hyperthermia • Hypercarbia • Increased 2,3-DPG • Sickle Cell Hb • Pregnancy • Volatile anesthetics • Chronic anemia
O2 dissociation curve: Left Shift means
(higher affinity for O2 = decreased unloading at tissues)
O2 dissociation curve shifts to the LEFT with
• Alkalosis • Hypothermia • Hypocarbia • Decreased 2,3-DPG • CO-Hb • Met-Hb • Sulf-Hb • Fetal Hb • Myoglobin
The P50 is the oxygen tension at which
hemoglobin is 50% saturated.
The normal P50 is
26.7 mm Hg. or 27 mmHg
The gold standard of verification is sustained detection of D tube positively identified in it,
expired carbon the endotracheal tube is placed in the dioxide.irect visualization of the laryngeal inlet with the endotracheal trachea and not the esophagus
Therefore, absence of Petco2 indicates
esophageal intubation, circuit disconnection, cardiac arrest, or airway obstruction.
A false-positive result may be obtained after
gastric inflation with CO2 containing gas or digestion of carbohydrate-enriched beverages. E
ETT-misplacement can be excluded by observing a
normal Petco2 waveform for three to six consecutive breaths.
An end-tidal C02 (ETC02) partial pressure of< 5 mm-Hg is diagnostic of what
Esophageal intubation.
Reliable signs to avoid esophageal intubation
auscultation of the chest and abdomen
full chest excursion
humidity in the ETT
detection of expired carbon dioxide with a capnograph or disposable colorimeter (Easy Cap) also provide
reliable evidence of tracheal rather than esophageal intubation.
Esophageal probe contraindicated in
The patient who has an esophageal perforation and the patient with liver disease who has or could have esophageal varices. Do not instrument the esophagus of these patients.
may also cause an increase in CO2 concentration.
A leak or obstruction in the anesthesia machine circuit, common gas outlet, or fresh gas supply line
“Curare” cleft—seen normally in the last part of phase III caused by a
lack of synchrony between diaphragm and intercostal muscles in a patient who has received neuromuscular-blocking agents and in whom muscle strength is returning.
Drugs with significant renal excretion with anesthesia \
AACDENN
Aminoglycosides Atenolol Cephalosporins Digoxin Edrophonium Nadolol Neogstimine
Drugs with significant renal excretion with anesthesia
4Ps and QRS
Pancuronium PCN Procainamide Pyridostigmine Quinolones Rocuroncium Sugammadex
CYP2C19 Substrate
POWD Propranolol Omeprazole Warfarin Diazepam
Cyclic Guanosine Monophosphate (cGMP) target responses
Activate protein kinase
Cyclic Guanosine Monophosphate (cGMP) common drugs effectors are
Nitroglycerin
Sodium Nitroprusside
Phosphoinositides and calcium : Target responses
Activate Calmodulin
Phosphoinositides and calcium : common drug effector
Lithium
Cyclic Adenosine monophosphate cAMP (CMC)
Caffeine
Milrinone
Catecholamines
Cyclic AMP responses
Release protein kinases
Beta receptor stimulation of energy release
Inotropic and chronotropic cardiac effects
Production of adrenal and sex steroids
Many endocrine and neural processes
Distance to the Junction of the Venae Cavae and Right Atrium from Various Distal Anatomic Sites Subclavian
10cm
Distance to the Junction of the Venae Cavae and Right Atrium from Various Distal Anatomic Sites Right Internal J vein
15 cm
For example, at a PO2 of 40 mm Hg, Hgb is approximately
75% saturated
Phenytoin on NDNMB
shortens the duration of action of the nondepolarizing neuromuscular junction blocking agents by inducing CYP3A4 and therefore increasing elimination
clearance of the drug.
The patient undergoing surgery has a decline in core
body temperature that occurs via five mechanisms:
(1) redistribution,
(2) radiation
(3) conduction
(4) convection
(5) evaporation.
Redistribution is the transfer of heat from
the peripheral compartments of the body to the central core
