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NUNA 680 - Pharm > TIVA > Flashcards

TIVA Flashcards

1
Q

What is a TIVA?

A

Total intravenous anesthetic - an anesthetic including intravenous agents only; CAN be combined with nitrous oxide and regional.

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2
Q

Advantages of TIVA (8)

A

Smooth induction with minimal coughing/hiccups
Easier control of anesthetic depth
Rapid, predictable emergence with minimal hangover
Decreased incidence of emergence delirium (disputed)
Lower incidence of PONV
Non-triggering for MH
Improved mucociliary transport
Improved V/Q matching

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3
Q

For what kind of surgery is TIVA particularly advantageous?

A

Neurosurgery; reduced CBF and CMRO2; allows intraop neuro monitoring; also, autoregulation of CBF is better maintained as volatile agents can cause a dose-dependent decrease in autoregulation

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4
Q

For which organ does TIVA present an advantage over volatile?

A

Kidneys

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5
Q

What makes TIVA preferable for a rigid bronchoscopy?

A

Prevents atmospheric pollution in the OR with the lack of a closed system present with rigid bronch

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6
Q

For what kind of non-surgical procedure is TIVA used? Why?

A

ECT; very brief GA needed; patients can wake up quickly from propofol

Propofol is an anticonvulsant that could potentially decrease the effectiveness so ECT, however, ketamine decreases seizure threshold, so the two can be used together to balance each other’s effects

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7
Q

What is an advantage of TIVA noted in ENT surgery?

A

Decreased bleeding in surgical field

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8
Q

Disadvantages of TIVA (4)

A

Increased post-op analgesic demands and cost
Decrease in forced vital capacity after operation greater than BAL with sevo
Greater cost
No effect on emergence delirium in peds

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9
Q

Indications for TIVA (7)

A

MH-susceptible patients
CF patients
AW endoscopies, laryngeal and tracheal surgery
Remote cases and during transport
ECT
Intracranial hypertension
Emergence delirium prevention (with Precedex but not Ketamine)

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10
Q

What are the advantages of continuous infusion TIVA over intermittent bolus TIVA? (6)

A 
Minimize swings in drug levels
Reduce total drug requirements by 25-30%
Fewer side effects
Shorter recovery time/awakening
Decreased drug costs
Stable depth of anesthesia
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11
Q

How does a bolus dose induction vs a continuous dose induction compare in TIVA?

A

Bolus caused rapid onset of unconsciousness but decreased BP and apnea as well as requiring more drug.

Continuous infusion cause slower loss of consciousness but lower dose of drug required and side effects minimized.

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12
Q

____ is similar between TIVA without __-______ and volatile with __-______.

A

PONV; anti-emetic; anti-emetic

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13
Q

What is the only IV anesthetic that can be used as a sole anesthetic agent in TIVA?

A

Ketamine

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14
Q

Ketamine is particularly good for what kind of patients?

A

Trauma, hypovolemia

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15
Q

Ketamine could have an adverse effect on patients with what diagnoses?

A

CAD, pulmonary htn, increased ICP

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16
Q

What effect does ketamine have on ED in patients with PTSD?

A

Decrease

17
Q

What are the benefits of using ketamine with propofol?

A

Offsetting hemodynamic and respiratory effects

Propofol offsets PONV and hallucinations

18
Q

What are the advantages of remifentanil use in TIVA?

A

Rapid onset, highly potent
CSHT does not increase regardless of length of infusion (plasma esterases)
Easily titratable
Quick emergence, less PONV

19
Q

Disadvantage of remifentanil

A

Hyperalgesia, shivering; requires initiation of post-op analgesia before discontinuing remi

20
Q

What are indications for dexmedetomidine?

A

Sedation, anxiolysis/ED, analgesia; can’t induce unconsciousness alone

21
Q

How does recovery of TIVA doses of dexmedetomidine compare with propofol?

A

Recovery is longer with dexmedetomidine at doses required for anesthesia

22
Q

What is the advantage of combining Precedex with propofol?

A

Deep sedation with cardiovascular stability and fewer adverse effect than either drug alone; reduced need for opioids and decreased PONV

23
Q

What is the most reliable sign of inadequate anesthesia?

A

MOVEMENT

24
Q

Since movement is the best indicator for TIVA titration, what factors should the CRNA consider in monitoring the patient?

A

Maintain 1-2 TOF twitches to allow movement

Use BIS monitor

25
Q

Define half-time

A

Time required for concentration in the central compartment to decrease by 50%

26
Q

What does context-sensitive half-time take into consideration?

A

Duration of infusion

Guides d/c of infusions for emergence

27
Q

Propofol maintenance infusion rate

A

50-150 mcg/kg/min

28
Q

What equipment is indicated for TIVA?

A

Large syringes, low volume tubing, single stopcock, multiple stopcock, labels, infusion pump (set for drug, kg, rate, concentration, bolus), t-piece for IV

29
Q

Troubleshooting during a TIVA, the CRNA may discover that the infusion is not reaching the patient because…(4)

A

Tubing is disconnected
Infusion pump is incorrectly programmed
Plunger is not in clamp
Stopcock is closed

30
Q

In cases of what length TIVA and BAL have equal hemodynamic stability and similar recovery?

A

Up to 1 hour

31
Q

Why do some CRNAs dislike TIVA?

A

Set-up takes longer

32
Q

What is a TCI? By what variable do they titrate?

A

Target-controlled infusion systems are pumps that the CRNA may program with the patient’s, weight, height, and age, and will administer medication based on a pharmacokinetic model of elimination and redistribution.

Predicted blood concentrations of drug

33
Q

Since most pharmacokinetic models are developed in ____, _______, and _________ _________ - use caution with patients with ____________, ________, _______, _________ ______ ________, and ________.

A

young; healthy; non-obese volunteers; co-morbidities; elderly; obese; critical care infusions; pediatric

Use BIS and titrate to clinical effect!

34
Q

Ketamine may cause a paradoxical increase in…

A

pEEG

NUNA 680 - Pharm (8 decks)

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