Anesthesiology From Miller

Front 1

These structures control sleep-wake cycle and are directly modulated by general anesthetics structures in the brainstem, _________, and basal _______________

Back 1

diencephalon
forebrain

Front 2

critical for memory and play a role in anesthetic-induced amnesia

hint; limbal critical

Back 2

Limbic system structures such as the hippocampus and amygdala

Front 3

contents of consciousness are thought to be generated by the

Back 3

cortex

Front 4

state of anesthesia divided into various behavioral end points including
(hint: haai and blunting...)

Back 4

amnesia, hypnosis, analgesia, immobility, and blunting of autonomic reflexes.

Front 5

slow wave sleep also known as

Back 5

non-REM sleep (NREM)

Front 6

prolonged sleepiness is also known as

Back 6

hypersomnolence

Front 7

sleep promoting region of brain

Back 7

anterior hypothalamus near optic chiasm

Front 8

wake promoting region of brain

Back 8

posterior hypothalamus

Front 9

the states of sleep and wakefulness may be characterized physiologically by

Back 9

recording EEG and electromyogram (EMG)

Front 10

on EEG, wakefulness is characterized by

Back 10

fast-frequency, low amplitude rhythm on the EEG that is "desynchronized", together with maximal motor activity on the EMG

Front 11

zosyn

Back 11

Piperacillin and Tazobactam for Injection, USP

To reduce the development of drug-resistant bacteria and maintain the effectiveness of ZOSYN® (piperacillin and tazobactam) injection and other antibacterial drugs, ZOSYN (piperacillin and tazobactam) should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria.

ZOSYN, piperacillin/tazobactam parenteral combination, is a white to off-white sterile, cryodesiccated powder consisting of piperacillin and tazobactam as their sodium salts packaged in glass vials. The formulation also contains edetate disodium dihydrate (EDTA) and sodium citrate.

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Call your doctor at once if you have any of these serious side effects:

diarrhea that is watery or bloody;
easy bruising or bleeding, unusual weakness;
dry mouth, increased thirst, confusion, increased urination, muscle pain or weakness, fast heart rate, feeling light-headed, fainting;
fever, chills, body aches, flu...

Before using piperacillin/tazobactam, tell your doctor or pharmacist if you are allergic to either of the drugs; or to penicillin, cephalosporin, or beta-lactam antibiotics; or to other beta-lactamase inhibitors such as sulbactam; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems.

Front 12

Bispectral index (BIS)

Back 12

is one of several technologies which purport to monitor depth of anesthesia. BIS monitors are intended to replace or supplement Guedel's classification system for determining depth of anesthesia. Titrating anesthetic agents to a specific bispectral index during general anesthesia in adults (and children over 1 year old) allows the anesthetist to adjust the amount of anesthetic agent to the needs of the patient, possibly resulting in a more rapid emergence from anesthesia. Use of the BIS monitor is thought to reduce the incidence of intraoperative awareness in surgeries.

Front 13

Orthostatic hypotension

Back 13

also known as postural hypotension, and colloquially as head rush or dizzy spell, is a form of hypotension in which a person's blood pressure suddenly falls when standing up or stretching. The symptom is caused by blood pooling in the lower extremities upon a change in body position. It is quite common and can occur briefly in anyone, although it is particularly prevalent among the elderly, and those with low blood pressure.

Front 14

Orthostatichypotension is quite common (about 20%) in the elderly and may result from _______________.

Back 14

diminished baroreceptor responsiveness

Front 15

What is blunted with aging?
Heart rate responses to these three things.

Back 15

heart rate responses to:
1. changes in BP,
2. the Valsalva maneuver, and 3. the respiratory cycle

Front 16

Valsalva maneuver

Back 16

is performed by moderately forceful attempted exhalation against a closed airway, usually done by closing one's mouth, pinching one's nose shut while pressing out as if blowing up a balloon. Variations of the maneuver can be used either in medical examination as a test of cardiac function and autonomic nervous control of the heart, or to "clear" the ears and sinuses (that is, to equalize pressure between them) when ambient pressure changes, as in diving, hyperbaric oxygen therapy, or aviation.

Front 17

Physiological response to Valsalva maneuver 1)

Back 17

1.Initial pressure rise
On application of expiratory force, pressure rises inside the chest forcing blood out of the pulmonary circulation into the left atrium. This causes a mild rise in stroke volume.

Front 18

Physiological response to Valsalva maneuver 2)

Back 18

2.Reduced venous return and compensation
Return of systemic blood to the heart is impeded by the pressure inside the chest. The output of the heart is reduced and stroke volume falls. This occurs from 5 to about 14 seconds in the illustration. The fall in stroke volume reflexively causes blood vessels to constrict with some rise in pressure (15 to 20 seconds). This compensation can be quite marked with pressure returning to near or even above normal, but the cardiac output and blood flow to the body remains low. During this time the pulse rate increases.

Front 19

Physiological response to Valsalva maneuver 3)

Back 19

3.Pressure release
The pressure on the chest is released, allowing the pulmonary vessels and the aorta to re-expand causing a further initial slight fall in stroke volume (20 to 23 seconds) due to decreased left ventricular return and increased aortic volume, respectively. Venous blood can once more enter the chest and the heart, cardiac output begins to increase.

Front 20

Physiological response to Valsalva maneuver 4)

Back 20

4.Return of cardiac output
Blood return to the heart is enhanced by the effect of entry of blood which had been dammed back, causing a rapid increase in cardiac output (24 seconds on). The stroke volume usually rises above normal before returning to a normal level. With return of blood pressure, the pulse rate returns towards normal.

Front 21

Deviation from the normal 4 stage response pattern to the Valsalva maneuver signifies either ___________or _______________ of the heart.

Back 21

abnormal heart function
abnormal autonomic nervous control

Front 22

Is vagal function reduced with aging?

Back 22

Yes.

Front 23

The primary autonomic defect in aging is...an impairment of reuptake of ____ - perhaps a function of ______________ nerve density.

Back 23

NE
decreased

Front 24

The ability to manipulate the pressure of __________ and _________ in tissues has contributed a great deal to the success of intensive care medicine.

Back 24

oxygen
carbon dioxide

Front 25

The fundamental pharmacokinetic processes of anesthesia are __________ into volumes of distribution and ____________. These processes are governed by the physical properties of the drug and the metabolic capacity of the patient. Anesthetic drugs tend to be highly bound to _________ in plasma and highly bound to lipid in peripheral tissues. Most anesthetic drugs are metabolized in the ___________.

Back 25

dilution
clearance
protein
liver

Front 26

The pharmacokinetics of anesthetic drugs are typically described by mathematical models with a central compartment and one or two peripheral compartments. These compartments do not directly correspond to any anatomic or physiologic structures. Computer simulations can be used to predict the ____________ of plasma concentration and drug effect after any dose.

Back 26

time course

Front 27

Drugs exert their effects through binding to receptors. The fraction bound is determined by the law of _______, which yields a __________ relationship between fractional occupancy and drug concentration.

Back 27

sigmoidal
mass action

Front 28

Drugs can be (acronym: PAIN) agonists, partial agonists, neutral antagonists, or inverse agonists. Receptors can exist in many states, but for simplicity, one can think of them as having just two states: activated and inactivated. The intrinsic efficacy of a drug is determined by the extent to which it ______________ the active form of the receptor (agonists) or the inactive form (inverse agonists) or simply displaces agonists from the binding site without favoring either form (neutral antagonists).

Back 28

stabilizes

Front 29

A fraction of receptors are in the activated state when drug is present. Thus, a “baseline effect” in the absence of drug does not represent the true baseline if all receptors are inactivated. This can be observed only by giving an inverse agonist that forces nearly all receptors into the _______________ state.

Back 29

inactivated

Front 30

Four main receptor types of relevance in anesthesia are ________________ (opioids, catecholamines), ligand-gated ion channels (hypnotics, benzodiazepines, muscle relaxants, ketamine), voltage-gated ion channels (local anesthetics), and enzymes (neostigmine, amrinone, caffeine). The first three are located in cell membranes. Enzymes can be located anywhere.

Back 30

G protein–coupled receptors

Front 31

Many drugs act through second messengers, which amplify drug action. Common second messengers are ___________, which can release stimulating or inhibitory subunits in response to drug binding at the receptor; cyclic adenosine monophosphate, which is frequently a target of G protein stimulation or inhibition; inositol 1,4,5-triphosphate and diacylglycerol, also targets of G-protein regulation; and intracellular ions, especially calcium.

Back 31

G proteins

Front 32

Advances in molecular pharmacology are helping identify the specific function of individual receptors, the role of individual amino acids in mediating receptor action, and the specific sites of action of many anesthetic drugs. Tools to explore the mechanism of drug action include site-directed mutagenesis to create “designer” receptors and knock-out/knock-down (underexpressed) or ___________ (overexpressed) murine models to understand the physiologic action of individual receptors.

Back 32

transgenic

Front 33

The fundamental properties of the concentration-versus-response relationship are potency and efficacy. Potency is the concentration associated with a 50% drug effect. ____________ is the maximal possible drug effect.

Back 33

Efficacy

Front 34

Drugs can interact both pharmacokinetically, through _______________ induction or inhibition, or pharmacodynamically, through synergy or antagonism. Anesthetic techniques typically take advantage of the synergy between hypnotics and opioids to produce the anesthetic state at far lower doses of each drug than would be required if they were used alone.

Back 34

enzymatic

Front 35

Pharmacogenetics is gradually explaining some of the variability in response to drugs. _______________ variability in pharmacokinetics can be attributed to variability in hepatic cytochromes (e.g., CYP2D6, CYP2C19), circulating enzymes (e.g., pseudocholinesterase), or transporters. Genetic variability in pharmacodynamics can be attributed to alterations in receptors, as has been demonstrated for multiple adrenergic receptor variants. Malignant hyperthermia has been clearly linked to variability in the ryanodine receptor.

Back 35

Genetic

Front 36

Variability in response to drugs can also be attributed to nongenetic causes, such as aging, disease, exposure to environmental toxins, and the pharmacokinetic or pharmacodynamic influence of other drugs. Variability is also introduced through continuous exposure to a single drug, which can trigger __________ (tolerance) or, if the drug is an antagonist, increased receptor sensitivity to the agonist.

Back 36

desensitization

Front 37

"Even if you're on the right track,

Back 37

you'll get run over if you just sit there." `W. Rogers

Front 38

emesis is

Back 38

vomit

Front 39

The presence of a significant acid-base abnormality often signals a serious __________ problem.

Back 39

underlying

Front 40

All acid-base abnormalities result from alterations in the dissociation of ____________.

Back 40

water

Front 41

Only three factors independently affect acid-base balance—the ______, the strong ______ difference (SID), and the total concentration of ______ acids (ATOT).

Back 41

Paco2
ion
weak

Front 42

Respiratory acidosis is caused by __________, and respiratory alkalosis is caused by ____________.

Back 42

hypercarbia
hypocarbia

Front 43

Metabolic acidosis is caused by decreased __ or increased ______. Decreased SID results from accumulation of metabolic _____ (shock, ketoacidosis, and renal failure), hyperchloremia, and free water excess. Increased ATOT results from __________.

Back 43

SID ATOT
anions
hyperphosphatemia

Front 44

Most acid-base disorders are treated by reversal of the _________.

Back 44

cause

Front 45

Alterations in the relative concentrations of hydrogen and hydroxyl moieties, widely described as disorders of __________ chemistry, are associated with significant clinical problems.

Back 45

acid-base

Front 46

Many clinicians struggle to understand acid-base chemistry because traditional educational approaches have focused on interpretation of _________ data, rather than an understanding of underlying biophysical chemistry.

Back 46

laboratory

Front 47

A key to understanding acid-base chemistry is the realization that acid-base abnormalities are secondary phenomena; they result from other biochemical changes in the ______________ environment.

Back 47

extracellular

Front 48

Acid - Base Physiology: Alterations in the relative concentrations of hydronium and hydroxyl are _______ important than the chemical abnormalities causing them.

Back 48

less

Front 49

Hydrogen (hydronium) and hydroxyl are the ion dissociation products of water and are modulated to maintain electric _______ in response to changes in the local concentration of strong ions, weak acids, and carbon dioxide (CO2).

Back 49

neutrality

Front 50

The extent to which water self-ionizes is minuscule. In pure water at 25°C, the [H+] and [OH−] are __________ mmol/L.

Back 50

H20 <-> H+ and OH-
1 × 10−7

Front 51

The molarity of water is extremely high—____ (“there is a lot of water in water”).

Back 51

55.5M

Front 52

The concentration of water and the Keq are ____________.

Back 52

constants

Front 53

Kw =______________
The implication is that the relative concentrations of hydroxyl and hydrogen are ________, so when there is an increase in the concentration of hydrogen ions, there is a concomitant decrease in the concentration of hydroxyl ions, and vice versa.

Back 53

[H+][OH-]
constant

Front 54

The concept of acids and bases is relatively new. In the early part of the 20th century, it was known that in critical illness the ______ content of the blood decreased.

Back 54

CO2

Front 55

In 1831, O'Shaughnessy identified loss of “carbonate of soda” from the blood as a fundamental disturbance in patients dying of cholera.[2] We now know that the loss of bicarbonate was related to hyperventilation and __________ of free hydrogen ions in dysoxic or dysmetabolic states.

Back 55

buffering

Front 56

In an aqueous solution, an Arrhenius acid is any substance that delivers a _________ into the solution.

Back 56

hydrogen ion

Front 57

Lactic acid, which has an ion dissociation constant (pKa) of 3.4, is completely dissociated at physiologic pH and is a ________ acid.

Back 57

strong

Front 58

Carbonic acid, which has a pKa of 6.4, is incompletely dissociated at physiologic pH and is a ________ acid.

Back 58

weak
H2CO3

Front 59

Carbonic Acicd

Back 59

H2CO3

Front 60

Ions such as sodium, potassium, and chloride that do not easily bind other molecules are considered _________ ions—they exist free in solution.

Back 60

strong

Front 61

In any solution, the ion dissociation constant for water, KW′, dictates that the relative ratio of [H+] to [OH−] must always be constant, and electric neutrality must always hold. Consequently, strong cations—Na+, K+, Ca2+, Mg2+—act as Arrhenius bases (because they drive _______ out of, and hydrogen into, solution, to maintain electric neutrality), and strong anions—Cl−, LA−, ketones, sulfate and formate—act as Arrhenius acids.

Back 61

hydroxyl

Front 62

hydroxyl group

Back 62

OH-

Front 63

The Arrhenius definition can be summarised as "Arrhenius _____ form hydrogen ions in aqueous solution with Arrhenius bases forming hydroxide ions."

Back 63

acids

Front 64

As defined by Arrhenius, acid–base reactions are characterized by Arrhenius acids, which dissociate in aqueous solution to form hydrogen ions (H+),[6] and Arrhenius bases, which form ____________ ions.

Back 64

hydroxide (OH−)

Front 65

A strong base is a basic chemical compound that is able to __________ very weak acids in an acid-base reaction. Common examples of strong bases are the hydroxides of alkali metals and alkaline earth metals like NaOH and Ca(OH)2. Very strong bases are even able to deprotonate very weakly acidic C–H groups in the absence of water. Here is a list of several strong bases:

Potassium hydroxide (KOH)
Barium hydroxide (Ba(OH)2)
Caesium hydroxide (CsOH)
Sodium hydroxide (NaOH)
Strontium hydroxide (Sr(OH)2)
Calcium hydroxide (Ca(OH)2)
Lithium hydroxide (LiOH)
Rubidium hydroxide (RbOH)
The cations of these strong bases appear in the first and second groups of the periodic table (alkali and earth alkali metals).

Back 65

deprotonate

Front 66

[H+], [OH-], and [HCO3-] are ____ independent variables in acid-base physiology

Back 66

NOT

Front 67

•The Henderson-Hasselbalch equation accurately describes the relationship among H+, PCO2, and HCO3, but does not describe the _______ for the system.

Back 67

"control"

Front 68

SID is always positive in human ECF, and _______ ions almost always exceed hydrogen ions quantitatively in solution.

Back 68

hydroxyl

Front 69

Stewart's pioneering work revealed several facts regarding [H+] that had not previously been understood. SID is always __________ in human ECF, and hydroxyl ions almost always exceed hydrogen ions quantitatively in solution. The relationship between SID and [H+] is nonlinear in these conditions. Any change in SID changes [H+] and [OH−] concentrations. Because of the water dissociation constant, this relationship is inverted: As [H+] increases, [OH−] decreases. SID is an independent variable; [H+] and [OH−] are dependent, meaning that the addition of hydrogen ions alone (without strong corresponding anions), cannot influence the pH of the solution.

Back 69

positive

Front 70

gamblegram

Back 70

for viewing anions cations