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228 Cards in this Set
- Front
- Back
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Hypotension is defined by a MAP < ____mmHg and a systolic BP < ___mmHg.
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MAP < 65 mmHg
Systolic BP < 80 mmHg |
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How is systolic BP measured?
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Doppler
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How is MAP measured?
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Direct or indirect
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What are some clinical signs of hypotension?
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Weak peripheral pulses
Pale mm Tachycardia +/- response to surgical stimuli |
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What are some complications associated with hypotension?
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Decreased renal perfusion, renal ischemia, renal failure
Vasodilative shock, cardiac arrest Equines - post anesthetic myopathy |
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#1 cause of hypotension in young and otherwise healthy veterinary patients:
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Anesthetics
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What is the mechanism associated with hypotension?
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Decreased preload
Decreased myocardial contractility Decreased PVR |
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The second most common cause of hypotension in young and otherwise healthy veterinary patients:
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Blood loss during surgery
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Name some disease processes that can exacerbate a hypotensive event:
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Hypovolemia
Shock Cardiomyopathy Valvular disease Hypothyroidism Hypoxemia Addisonian crisis |
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When you first notice that an animal is hypotensive under surgical anesthesia, what do you do?
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Turn down the vaporizer
Turn up the fluids |
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You have a patient anesthetized and he is hypotensive. He has sustained a lot of blood loss during surgery and neither decreasing the MAC nor increasing fluids is helping. You check a PCV and find that it is below 25. What should you do?
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Blood transfusion
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Name a couple sympathomimetic drugs that can be used to treat hypotension as a second line of defense (after you have tried fluids and decreasing the MAC).
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Dopamine
Dobutamine Vasopressin Ephedrine |
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When partial pressure of O2 in arterial blood drops below 60 mmHg, this is known as:
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Hypoxemia
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A Pulse-Ox reading below 90% is AKA:
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Hypoxemia
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Hypoxemia leads to ______ and is a frequent cause of mortality in vet patients undergoing anesthesia.
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Cardiac arrest
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What are some causes of hypoxemia?
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Decreased inspiration O2 concentration
Hypoventilation VQ mismatch Shunt or venous admixture Diffusion barrier The veterinarian |
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What is the #1 cause of anesthetic death?
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Failure to maintain patent airway leading to hypoxemia
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What are some veterinarian mistakes that can lead to hypoxemia and patient death?
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Unrecognized extubation
Disconnection Aspiration Kinked ET tube Failure to turn off oxygen Closed pop off valve Empty oxygen cylinder OD of anesthetic drugs |
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How do you manage hypoxemia?
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Check the ET tube
100% oxygen Heart ok? Manual ventilation |
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What is the definition of hypercarbia?
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When arterial CO2 or end tidal CO2 is > 50 mmHg
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When arterial CO2 or end tidal CO2 is > 50 mmHg, this is known as:
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Hypercarbia
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Normal CO2 in the awakened patient:
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35-45 mmHg
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True/false: Anesthetic drugs depress the respiratory drive in a dose dependant fashion.
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True
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True/false: Patients with mild to moderate hypercarbia is usually not a concern unless it is a patient with increased intracranial pressure.
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True
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Increased BP, increased pulse pressure, increased SV, contractility and HR, but a decreased SVR represents which of the three: hypovolemia, hypoxemia, or hypercarbia?
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Hypercarbia
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Clinical signs of hypercarbia:
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Tachycardia
Hypertension Shallow respiration with increased rate/decreased tidal volume |
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True/false: Hypercarbia and associated shallow breathing results in respiratory alkalosis.
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False - respiratory acidosis. Remember, its a bit like holding your breath. [H+] will increase on the opposite side of the equation, meaning your pH is dropping
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Respiratory acidosis due to hypercarbia results from which - decreased elimination of CO2 or increased production of CO2?
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Decreased elimination
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How do you treat hypercarbia?
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Control ventilation
Decrease MAC 'Sigh' patients periodically |
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True/false: A cardiac dysarrhythmia is significant only if the hemodynamic status of the patient is affected.
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True
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Are all inhalant anesthetic agents myocardial depressants in a dose dependant fashion?
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YES
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What are our two main anticholinergics?
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Atropine and glycopyrrolate
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How can atropine and glycopyrrolate affect the heart?
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Sinus tachycardia
2nd degree AV block |
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Acepromazine is what type of drug?
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Phenothiazine
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What affect can Ace have on the heart?
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Sinus tachycardia
Alpha-1 adrenergic blockade |
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How can opioids affect the heart under anesthesia?
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Bradycardia
2nd degree AV block |
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Which barbiturate causes bigeminy?
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Thiopental
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This condition describes a state where your heart alternates one "normal" beat with one "premature" beat:
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Bigeminy
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Most common dysarrhythmia seen under anesthesia:
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Sinus bradycardia
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Sinus bradycardia in a large breed dog is when you have <___ bpm.
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60
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Sinus bradycardia in a small breed dog is when you have <____ bpm.
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70
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Sinus bradycardia in a cat is when you have <____ bpm.
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100-120
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True/false: A second degree AV block can sometimes be present with sinus bradycardia.
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True
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If palpated pulses are slower but strong and auscultation reveals a slow heart rate with regular rhythm this is AKA:
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Sinus bradycardia
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Describe the ECG of a patient with sinus bradycardia.
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Normal p-wave for each QRS
Constant P-R interval |
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What are some contributing factors for a sinus bradycardia?
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Increased PNS activity
Increased vagal tone Decreased SNS output |
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What are some causes of sinus bradycardia?
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Drugs
Vagal mediated reflexes Hypothermia Hypothyroidism Addison's disease Excessively deep planes of anesthesia |
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If you have a dog with a high vagal tone resulting in sinus bradycardia, what can you treat him with?
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Anticholinergics (like atropine to increase the HR)
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If you suspect that opioids are causing sinus bradycardia, what can you do?
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Give reversal or anticholinergics
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Sinus tachycardia in a large breed dog is when you have more than ____ bpm.
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160
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Sinus tachycardia in a small breed dog is when you have more than ___ bpm.
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180
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Sinus tachycardia in a cat is when you have more than ___ bpm.
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220
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What are some contributing factors to sinus tachycardia?
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Sympathetic response to surgery
Pain Hypovolemia Shock Hypercarbia Uncontrolled disease process |
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Why are we concerned with sinus tachycardia?
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Because the rate can become so high that there is inadequate time for ventricular filling (decreased CO and BP)
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If your patient is hypovolemic and this is leading to tachycardia, what can you do?
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Increase fluids
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If your patient is hypercarbic and experiencing tachycardia, what can you do?
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Increase ventilation
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True/false: Most supraventricular atrial tachycardias are usually well tolerated under anesthesia.
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True
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What are some supraventricular atrial tachycardias?
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A-fib
A-flutter A-tach |
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When PVCs originate as electrical impulses generated below the AV node and AV junction, this is AKA:
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Ventricular dysarrhythmias
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During anesthesia, when do you get concerned about PVCs?
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When you have multifocal complexes or runs with increasing frequency
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If VPC's begin to occur in runs, what happens if you do not get them under control?
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Decreased CO
V-tach, V-fib, death |
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When p-waves are not associated with the QRS complex and the QRS complex is wide and bizarre, this is AKA:
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Ventricular arrhythmia - PVCs
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What are some causes of PVC's?
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Trauma patients with myocardial bruising
Electrolyte imbalances Acid/base disturbance Hypoxemia Hypothermia Bradycardia |
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If PVC's are getting out of hand, what can you treat them with?
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Lidocaine
Oxygen and ventilation Analgesics |
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Generally temps less than ____ are considered hypothermic.
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100.5
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When heat loss exceeds heat production, this is AKA:
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Hypothermia
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When is the greatest temperature loss during anesthesia?
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During the first hour
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At what body temp do you no longer see shivering?
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Below 89.6
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At what body temp do you see cardiac arrest?
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Below 82.4
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MAC decreases _____% for every 1 degree C drop in body temp.
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5-7%
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Shivering increases metabolic oxygen by ___%.
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200-300%
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True/false: Some heat loss is to be expected during surgery.
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True
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What three things lead to recovery excitement?
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Dysphoria
Pain Disorientation |
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What causes disorientation and thus recovery excitement?
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Too rapid emergence from anesthesia
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What causes dysphoria and thus recovery excitement?
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Too many opioids
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Can insufficient pain management cause recovery excitement?
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YES
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What are some benefits of pre-emptive pain management?
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Decrease MAC of inhalant
Quicker recoveries Lower overall pain scores Patient safety |
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What are the four main steps in pain processing?
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Transduction
Transmission Modulation Perception |
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You can inhibit peripheral sensitization of nocireceptors with which classes of drugs?
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NSAIDS
Opioids Local anesthetics |
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You can inhibit impulse conduction associated with pain with which classes of drugs?
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Local anesthetics
Alpha-2 agonists |
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You can inhibit central sensitization associated with pain with which classes of drugs?
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Local anesthetics
Opioids Alpha-2 agonists Tricyclic antidepressants Cholinesterase inhibitors NMDA antagonists NSAIDS |
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What are some drugs that can inhibit the perception of pain?
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Anesthetics
Opioids Alpha-2 agonists Benzodiazapines |
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Why is a multimodal approach to pain management so much better?
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Less dysfunction
Faster recovery More complete |
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Topical local anesthetics are used for:
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Desensitization of skin surfaces
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Local anesthetics used for infiltration and field blocks are good for:
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Local tissue desensitization
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Give an example of a regional local anesthetic technique:
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Epidural
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Give examples of systemic local anesthetic techniques:
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IM
IV SQ CRI |
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Three basic parts to an anesthetic molecule:
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Hydrophobic end
Hydrophilic end Intermediate chain |
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Which is metabolized by hepatic enzymes - amides or esters?
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Amides
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Which undergoes hydrolysis by plasma cholinesterase, amides or esters?
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Esters
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Which is associated with PABA and allergies - esters or amides?
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Esters
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Which is associated with cross reactivities - esters or amides?
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Esters
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True/false: a drug's lipid solubility affects its ability to bind to axonal lipids and thus affects potency.
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True
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True/false: A drugs duration of effect can be affected by protein binding.
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True
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At rest, describe where K and Na relative to each other in/outside of a cell.
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Na outside
K inside |
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Describe how local anesthetics change neurophysiology.
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Binds to receptor sites in Na channel to prevent/impede Na movement (and thus effects depolarization)
Electrical impulses reduced; nerve conduction blocked |
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Dissociation ratio is determined by:
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pH and pKa
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Which can bind to a Na receptor, a charged or uncharged cation?
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Charged --> leads to neural blockade
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General parts of a neuron:
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Cell body
Axon Dendrites |
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Which is blocked first, sensory or sympathetic?
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Sympathetic
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Which is blocked first, sensory or motor?
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Sensory
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Which is blocked first, myelinated or unmyelinated?
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Myelinated
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Which is blocked first, small or larger neurons?
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Small
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Which is blocked first, faster or slower neurons?
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Faster
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Put in order of sensation: Touch, motor, pain, warmth, deep pressure, cold, joint
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Pain>cold>warmth>touch>joint>deep pressure>motor
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Which type of fiber has the slowest conduction velocity?
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C-fiber
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Which type of fiber has the fastest conduction velocity?
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A-alpha fiber
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Put in order of fiber stimulation: Aa, C, Ad, Ag, B, Ab
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B>C>Ad>Ag>Ab>Aa
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True/false: The effects of a neuronal block are reversed as a drug is metabolized and redistributed.
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True
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Procaine, Benzocaine and Proparacaine are all esters or amides?
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Esters
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Another name for Novocaine:
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Procaine
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What is benzocaine used for?
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Topical wound care
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What ester is used for ophthalmic anesthesia?
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Proparacaine
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Lidocaine, Mepivicaine and Bupivicaine are amides or esters?
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Esters
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Another name for Bupivicaine:
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Marcaine
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What can prolong the duration of lidocaine applied topically?
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Vasoconstriction
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Onset for lidocaine:
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10-15 mins
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Does lidocaine have a short or long duration?
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Short - 1-2 hrs (think of your tooth)
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Which has a longer duration of action - Lidocaine or Mepivicaine?
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Mepivicaine
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Which has a very rapid onset - Mepivicaine or Bupivicaine?
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Mepivicaine - 5-10 mins
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What other amide has 4x the potency of lidocaine?
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Bupivicaine
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Which has a lower MOS, and thus you need to carefully calculate doses - Lidocaine or Bupivicaine?
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Bupivicaine
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Which of the amide local anesthetics is the longest acting?
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Bupivicaine
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What is usually the 1st CNS sign seen w/ overdose of anesthetic agent?
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Muscle twitching
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What are some adverse CNS effects seen with local anesthetics?
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Muscle twitching
Convulsions Unconsciousness Coma Respiratory arrest |
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What are some adverse CV effects seen with local anesthetics?
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Profound vasodilation
Profound hypotension Direct myocardial depression Decreased ventricular contractility |
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If you have an adverse effect associated with a local anesthetic, what do you do?
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Fluids
Diazepam if seizuring Intubate 100% O2 |
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An unpleasant sensory and emotional experience (perception) associated with actual or potential tissue damage or described in terms of such damage is AKA:
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Pain
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The reception, conduction and CNS processing of nerve signals generated by nociceptors leading to the perception of pain is AKA:
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Nociception
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True/false: Nociception is the process that leads to the perception of pain.
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True
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What are the two types of nociceptors that convert chemical, mechanical or thermal energy into electrical impulses?
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Free A-delta and C nerve fibers
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Which nociceptors are composed of mechanoreceptors and mechanothermal receptors?
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A-delta nociceptors
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Describe a high threshold A-delta nociceptor.
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(<25%) - responds only to tissue damaging stimuli
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A-delta nociceptors can be broken into 2 subtypes:
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High threshold (<75%)
Low threshold (<25%) |
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Which discharges at a faster rate, A-delta nociceptors or C-fiber nociceptors?
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A-delta
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Which provides more discriminative information to the CNS - A-delta fibers or C-fibers?
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A-delta fibers
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Which is associated with 'first pain', the pricking or sharp quality, A-delta fibers or C-fibers?
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A-delta
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True/false: Almost all C-fibers are high threshold and respond to different types of stimuli (are polymodal)?
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True
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Which nerve fiber is associated with second pain?
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C-fiber
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What are the qualities of second pain, associated with C-fibers?
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Burning and aching qualities
Signals tissue damage and inflammation that initiates self preservation behaviors |
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What are silent, or sleeping nociceptors important for?
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Peripheral sensitization
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Describe silent/sleeping nociceptors.
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A-delta and C-fiber nociceptors that are activated by tissue damaging events
Important role in peripheral sensitization |
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The conversion of mechanical, chemical or thermal energy to an electrical impulse is what part of the pain pathway?
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Induction
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When eletrical signals are transmitted via nociceptors to the spinal cord, this process is AKA:
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Transmission
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Which is myelinated, A-delta fibers or C-fibers?
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A-delta
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Which has a smaller diameter, A-delta fibers or C-fibers?
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C-fibers
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Which has fast conduction, A-delta fibers or C-fibers?
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A-delta
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Which transmits well localized, sharp pricking pain, A-delta fibers or C-fibers?
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A-delta fibers
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Which is involved in second pain, A-delta fibers or C-fibers?
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C-fibers
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Amplification or supression of peripheral sensory nerve impulses at the level of the spinal cord is AKA:
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Modulation
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What is the role of interneurons?
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Part of modulation
Excitatory or inhibitory Transmit sensory information for a short distance in the spinal cord |
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What are propriospinal neurons involved in?
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Modulation
Segmental reflex activity - generate a simple motor withdrawl response |
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Where do projection neurons synpase with 3rd order neurons?
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Medulla
Pons Midbrain Thalamus Hypothalamus Cerebral cortex |
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What are the three types of neurons associated with modulation?
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Interneurons
Propriospinal neurons Projection neurons |
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Integration, processing and recognition of sensory information is AKA:
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Perception
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The descending pathway invovles which endogenous opioids?
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Dynorphins
Endorphins Enkephalins |
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The descending pathway begins where in the brain?
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Amigdala
Cortex Thalamus |
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Describe the progression of a signal down the descending pathway?
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Begins in Cortex, amigdala, thalamus
Goes to midbrain Goes to dorsal horn of the spinal cord Inhibition of transmission of impulses |
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Pain due to a stimulus which does not normally provoke pain and can be either static or mechanical is AKA:
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Allodynia
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Allodynia is associated with:
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Central sensitization
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Alteration in the excitability of the neurons in the brain and in the spinal cord caused by severe or chronic painful stimuli that activates A-delta and C-receptors is AKA:
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Central sensitization
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What is hyperalgesia and what is it associated with?
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Intensification of pain associated with central sensitization
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What are the two general ways we can classify pain?
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Duration
Origin |
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Which is usually related to trauma, surgery or infection, acute or chronic pain?
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Acute
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What type of pain persists beyond a reasonable time for the course of disease or injury?
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Chronic pain
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If you say your pain is somatic in origin, what does this mean?
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Originates from damage to somatic tissues - bones, joints, muscle, skin
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Is somatic pain well localized or not?
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YES, visceral pain is not
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Which can be associated with nausea or vomiting, somatic or visceral pain?
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Visceral
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What type of pain arises from visceral injury and is not well localized?
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Visceral pain
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What type of pain is associated with direct damage to the peripheral nerves or spinal cord?
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Neuropathic
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Describe neuropathic pain sensation:
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Burning or shooting pain
Difficult to treat |
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How is the immune system affected by pain?
|
Increased cortisol levels impair wound healing and decrease immune function
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Describe how the neuroendocrine system is affected by pain:
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Activated by pain
Gluconeogenesis is favored Impaired metabolism results in catabolism and cachexia |
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Describe how the GI system is affected by pain:
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Sympathetic stimulation can cause shunting of blood, decreased motility and decreased mucosal integrity
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With pain, the CV system can be affected by initiation of R-A-A, what is the effect of this?
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Fluid retention
Elevated BP Decreased renal profusion Increased HR, SV, CO and myocardial O2 consumption |
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What are the psychological effects associated with pain?
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Patient's quality of life is decreased
Owner gets angry, guilty and fearful of procedures Caregivers feel guilt if unable to treat pain |
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What is the 4th vital sign?
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Pain
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True/false: Pain assessment is considered part of every patient evaluation, regardless of presenting complaint.
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True
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What are the four general signs of pain?
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Loss of normal behavior
Expression of abnormal behaviors Reaction to touch Change in physiologic parameters |
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Give some examples of loss of normal behavior associated with pain.
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Decreased ambulation
Decreased appetite Decreased grooming (cat) Lethargic attitude |
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True/false: a change in normal behaviors associated with pain is difficult to assess in the hospital.
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True
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Describe some abnormal behaviors that may be expressed if an animal is in pain.
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Vocalization
Inappropriate elimination Aggression Altered facial expression Decreased interaction w/ pets and family members Altered posture Restlessness Hiding (cats) |
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How might your physiologic parameters change in association with pain?
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Increased HR, BP, RR, temp
Pupil dilation (mydriasis) |
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What type of pain scale is this?
|
Numerical - just like a simple descriptive scale except it has numbers also
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What type of pain scale is this?
|
Simple descriptive
|
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How can you improve the use of a visual analogue pain scale?
|
Specify procedure: Worst possible pain for THIS...
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What type of pain scale is this?
|
Visual analogue
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True/false: Pain scoring systems are very subjective with user variability.
|
True
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Describe the Dynamic and Interactive Visual Analogue Scale (DIVAS).
|
Observation from a distance undisturbed
Approached, handled and encouraged to walk Palpation of surgical incision and surrounding area Final overall assessment of sedation and pain |
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Describe the Glasgow composite measures pain score.
|
47 well defined words or expressions that could define pain
One physiologic and 7 behavioral categories |
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What are the 7 behavioral categories associated with the Glasgow Composite Measures Pain Score?
|
Posture
Comfort Vocalization Attention to Wound Mobility Demeanor and Response to Humans Response to Touch |
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Which quantitative pain scoring system looks at physiologic data and behavioral responses, and gives a pain score between 0 and 27?
|
University of Melbourne Pain Scale (UMPS)
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|
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What are the four general ways you can treat pain?
|
Inhibit transduction
Inhibit transmission Inhibit modulation Inhibit perception |
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What are full Mu agonist opioids generally used for?
|
Moderate to severe pain
|
|
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What are the full agonist opioids?
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Morphine
Oxymorphone Hydromorphone Fentanyl Methadone |
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Which opioid would I pick for very mild pain?
|
Agonist-antagonist
Butorphanol |
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Which opioid would I pick for moderate pain?
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Partial Mu agonist
Buprenorphine |
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Which opioid is a partial Mu agonist?
|
Buprenorphine
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Which opioid is an agonist-antagonist, and is used for mild pain?
|
Butorphanol
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|
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True/false: NSAIDS are inhibitors of COX-1 and COX-2 pathways.
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True
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What is the general mechanism of NSAIDS?
|
By inhibiting the COX-1 and COX-2 pathways, they prevent the conversion of arachadonic acid to prostanoids
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|
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Should I use an NSAID with renal or hepatic insufficiency?
|
NO
|
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What are some contraindications for NSAID usage?
|
Renal/hepatic problems
Dehydration/hypotension/shock Active GI disease Coagulopathy Current use of steroids or other NSAIDS Pregnancy |
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True/false: NSAID usage is contraindicated in pregnancy.
|
True
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Which classes of drugs provide analgesia?
|
Opioids
Alpha-2-agonists Dissociatives NSAIDS |
|
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Which parts of the pain pathway do local anesthetics act on?
|
Transduction
Transmission |
|
|
Which can you use IV, lidocaine or bupivicaine?
|
Lidocaine
|
|
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True/false: IV Lidocaine provides good visceral analgesia to horses in colic.
|
True
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Central sensitization and hyperalgesia is common with what injury?
|
Burn
|
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Can ketamine be used to prevent and treat central sensitization?
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YES (hence why it is used to treat burns)
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Name the routes by which ketamine can be given?
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IV, IM, SQ, epidural
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Name an adjuvant drug that is OFTEN used as a sedative.
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Ace
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What tricyclic antidepressant is often used as an adjuvant drug?
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Amitryptylline
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What is the nature of Gabapentin (i.e. what might it be used for)?
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Anticonvulsant
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How does tramadol affect GABA and serotonin?
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Increase them
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What is the benefit of using an opioid CRI, rather than just an injection prior to surgery?
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More constant plasma levels
Eliminates the need for repeated administration via other routes |
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Which opioid is given as a buccal transmucosal?
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Burprenorphine
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True/false: There is a big difference between giving something (like Buprenorphine) orally and giving it transmucosal in the buccal cavity.
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True! - With buccal transmucosal administration, there is NO first pass effect
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The peak effect of transdermal Fentanyl is felt in how many hours?
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12-24 (lasts about 72 hrs)
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What are the advantages to doing an epidural?
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Prolonged segmental analgesia
Minimal sedation Decreased MAC |
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What are the disadvantages to doing an epidural?
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Technical expertise required
Spinal needle necessary |
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What are some side effects of epidural usage?
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Urinary retention
Pruritis Vomiting Hypotension |
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When is an epidural contraindicated?
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Sepsis
Coagulopathies |
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True/false: Hematomas, abscesses and ineffective analgesia can all be complications associated with epidural usage.
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True
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I want to do a brachial plexus block. This means I want to work on what part of the leg?
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Within or below the elbow
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When might I use an intercostal nerve block?
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Rib fractures
Lateral intercostal thoracotomy |
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When you do an intercostal nerve block, do you go cranially or caudally to the rib?
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Caudal border of the rib
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When might I use interpleural analgesia?
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Thoracotomy
Rib fractures Pancreatitis Cholecystectomy Metastasis in the region |
