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81 Cards in this Set
- Front
- Back
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what are the 4 A's anesthesia |
analgesia, amnesia, akinesia, attenuation of autonomic response |
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what are the 4 stages of anesthesia |
analgesia, excitement (or delirium), surgical anesthesia (4 planes of anesthesia), imminent death |
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what is the general rule for minimum alveolar concentration |
1.3 times MAC |
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things that increase anesthetic concentration |
hypothermia cns depressants including acute alcohol ingestion increasing age severe hypercapnia (>90?) sever hypoxemia sever anemia (hct <10) |
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things that decrease anesthetic concentration |
fever cns stimulants decreasing age chronic alcoholism |
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what are the inhaled anesthetics |
nitrous oxide halothane isoflurane desflurane sevoflurane |
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what is nitrous oxide used for? |
sedation, analgesia, and amnesia; adjunct to inhalation or IV general anesthesia
NEVER use by itself bc it doesn't have any O2 in it |
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what is sevoflurane used for? |
induction and maintenance of general anesthesia |
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how do you get rid of anesthetic |
biotransformation transcutaneous loss exhalation |
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complications of nitrous oxide |
venous or arterial air embolism pneumo acute intestinal obstx with bowel distention intracranial air pul air cysts intraocular air bubbles tympanic membrane grafting |
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ADR of sevoflurane |
emergence agitation and/or delirium rare but cases of preoperative hyperkalemia rare but cases of QT prolongation potential to trigger malignant hyperthermia |
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what are the IC anesthetics |
propofol etomidate ketamine methohexital |
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what is propofol used for? |
-induction of anesthesia (older then 3y/o) -maintenance of anesthesia (older then 2mo) -adults: monitored anesthesia care sedation during procedures -sedation of intubated mechanically-ventilated ICU pts |
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kinetics of propofol |
RAPID onset RAPID recovery unaffected by obesity, cirrhosis, kidney failure be careful with elderly |
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ADR of propofol |
hypotension respiratory depressant histamine release decreased cerebral blood flow and intracranial pressure
good SE: antiprurtic, antiemetic, anti seizure, dependence/addiction rate low |
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what is the dose for proposal as a procedural sedation (unlabeled use) |
IV push initial .5-1mg/kg flowed by .5mg/kg q 3-5m PRN remember proposal has no analgesic properties |
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contraindications to propofol
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-hemodynamic instabilty, poor cardiac output, shock -allergy to any of the components (has food things it to make it a fatty substance) -extremely high serum TAG -very high ICP -pregnancy |
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what is PRIS |
propofol infusion syndrome -48h after infusion -acute bradyHR leading to systole, heart failure cariogenic shock, rhabdomyolysis, hyperlipidemia, fatty liver -failure of ETC, failure of ATP production (massive amt of lactate produced, FFA leak into bloodstream to make acidosis worse) |
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dose for propofol |
induction: 40mg q 10s until onset maintenance: infusion 6-12mg/kg/hr for 10 to 15m then 3-6 mg/kg/hr intermittent IV bolus 25-50mg increments |
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what is etomidate used for |
induction and maintenance of general anesthesia unlabeled use: sedation for dx of seizure foci, procedural sedation |
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kinetics of etomidate |
onset within 30-60s peak 1m duration 3-5m NO analgesic effect |
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SE of etomidate |
-myoclonus -cardio: mild reduction peripheral vascular resistance -respiratory -n/v -cortisol effect and etomidate long term use downfall |
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dose for etomidate |
start at 0.2-0.6mg/kg over 30-60s for induction and maintain at between 5-20mcg/kg/min
not approved for <10 y/o old |
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uses for ketamine |
inductionand maintenance of general anesthesia unlabeled use: analgesia, sedation |
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kinetics of ketamine |
onset IV 30s duration 5-10m awakening a result of redistribution from brain to peripheral tissue
ketamine HAS an analgesic properties |
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SE of ketamine |
-minimal effect on ventilatory drive -upper airway reflexes remain intact -ICP increases ? -emergence phenomenon: disturbing dreams and delirium during emergence and recovery- can reduce with bento or propofol |
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dose for ketamine |
induce with dose btw 0.5-2mg/kg and maintain anesthesia with 1-6mg/min dose |
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what are the barbiturates used for? |
methohexital
induction of anesthesia procedural sedation |
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kinetics of barbiturates |
methohexital
onset 30s duration 20m redistribution causes barbiturate coma rapid hepatic clearance than thiopental |
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SE of barbiturates |
cardiovascular: decr BP from vasodil, incr HR from central vagolytic effect and BP be careful in hypovolemia, heart failure, or beta adrenergic blockade
respiratory: decr ventilatory response, tidal volume and respiratory rate depressed on awakening
cerebral effect: constrict cerebral vasculture, NO ANGELSIC EFFECT, no muscle relaxtion
reduced renal and hepatic BF (and GFR) |
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dose for barbiturates |
Methohexital 1-1.5mg/kg x1 IV prior to surgery |
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what are the opioids |
fentanyl sufentanil alfentanil remifentanil |
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what would we use fentanyl citrate for? |
-relieft of pain, preoperative medication, adjunct to general or regional anesthesia -block stress response form CAT, cortisol, ADH -reduction of dose of other anesthetics like inhaled proposal, neuromuscular blockers -postoperative analgesia |
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kinetics of fentanyl |
onset <1m peak 3.6m duration 30-60m
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why don't we use morphine or meperidine and codeine during surgery |
histamine release- HOTN, bronchospasm lower fat solubility delays mvnt into thru BBB so duration prolonged
risk of biotransformation ped risk |
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SE of opioids |
cardiovascular: vagus nerve-mediated bradycardia, vendilation, decr sympathetic reflexes, depr cardiac contractility, intraopertive HTN respiratory: apneic threshold rises (hypoxic drive decr), chest wall rigidity cerebral: reductions in cerebral O2 consumption, ICP |
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when would you use meperidine over morphine or fentanyl after a surgery?
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IV meperidine is more effective thean morphine or fentanyl for decr shivering in PACU |
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what is opioid induced hyperalgesia |
pts beocme more senstive to painful stimul acute tolerance reported with large dose remifentainl need for more anaglesic help |
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dose for opioids |
fentanyl citrate injection IV start btwn 2-20mcg/kg then bolus or infuse btw 1-2mcg/kg/hr |
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what are the benzodiazepines |
medazolam diazepam lorazepam |
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what can you give to someone who is closterphobic and has to have a CT |
oral lorazepam 40-60m before |
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what can you use midazolam for? |
-induction of maintenance of general anesthesia -preoperative sedation -mod sedation prior to dx or radiographic procedures -ICU sedation (continuous infusion) |
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kinetics of midazolam properties |
T1/2 = 2h (long) onset: IV 2-3m IM 10-20m duration: IV 45-60m IM 10-20m |
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bad stuff about midazolem |
IM dose 2-3mg 30-60mg prior to procedure some pts may only need 1mg remember midazolam has NO analgesic properities always keep in single digit numbers?
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what is the reversal agent for benzos |
flemazenil specifitc to reversal of benzo dosing .2mg over 15s; repeat dose q 1m up to max 1mg |
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what is an unapproved use for midazolem |
effective in controling grand mal seizures (not approved) antegrade amnesia (good premed property) mild muscle-relaxing properties |
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SE of benzos |
cardiovascular: minimal, reduced BP, peripheral vascular resistance
respiratory: depressed ventilatory response, apnea uncommon |
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dose for benzo |
it depends on what its for if they are premedicated if they are older then 60yrs |
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what is the selective alpha 2 agonist |
Dexmedetomidine
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how does dexmedetomidine work |
inhibits NE increases GABA |
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what is dexmedetomidine used for |
-sedation prior to and/or during surgical or other procedures of non intubated pt -procedural sedation prior to and/or during awake fiberoptic intubation -sedation of initially intubated and mech ventilated pts during tx in intensive care setting |
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prcedural sedation for dexmedetomidine |
approved procedural sedation IV infusion loading inflation of 1mcg/kg (or .5 mug/kg for less invasive procedures) over 10m maintenance infusion of .6mcg/kg/hr ittrate to sediaed effect usual range .2-1mcg/kg/hr |
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dexmedetomidine therapy duration |
the manufacturer says less than 24h of therapy bc of withdrawal concern but recent studies indicate long therapy may be safe and effective |
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whats good about dexmedetomidine |
dose dependent sedation,anxiolysis, and analgesia does NOT significantly depress respiration
its better then benzos for the management of agitation in critally I'll pts |
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kinetics of dexmedetomidine |
onset 5-10m peak 15-30m duration 1-2h
hepatic and renal dysfunc |
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SE of dexmedetomidine |
bradycardia and HOTN nausea and dry mouth |
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dose for dexmedetomidine |
dexmedetomidine infusion load with infusion of 1mcg/kg over 10m than maintain at btw 0.2-0.7 mcg/kg/hr |
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what is the depolarizing NMBS |
Succinylcholine |
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is there a reversal agent for depolarizing NMBS? |
Succinylcholine
NO, it would make it worse bc the drug just diffuses away quickly |
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what is Succinylcholine used for |
facilitate both RSI and routine endotrach and to relax skeletal musc during surgery |
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kinetics of Succinylcholine |
rapid onset with complete mess realization after IV in 30-60s duration 4-6m
NO analgesic NO sedative
hypersensitivity rxns: bronchospasm, HOTN, flushing |
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SE of Succinylcholine |
cardio: arrhythmias, changes in BP, tachy
electrolyte abnl: hyperkalemia
neuromusc: jaw rigidity, muscl fasciculation, postoperative muscle weakness
malignant hyperthermia
prolonged muscle relaxation caused by excess drug, hypothermia, hypokalemia, etc. |
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dose for Succinylcholine |
Succinylcholine 20mg/ml 0.6mg/kg IV for intubation |
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what are the non-depolarizing NMBS |
Pancuronium Rocuronium Atracurium Cisatracurium Vecuronium |
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MOA of non-depolarizing NMBS |
occupies one ACH receptor site at NMJ stones any nerve transmission metabolized away by acetylcholinesterase |
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what is non-depolarizing NMBS used for |
facilitate RSI and routine ET intubation and to relax skeletal music during surgery facilitate mechanical ventilation in ICU |
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kinetics of non-depolarizing NMBS |
onset 1-2m peak 4m duration 30m |
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SE of non-depolarizing NMBS |
abnl EKG, anaphylactoid rxn, arrhythmias, etc.
careful with burn pts, heart failure, pul HTN, valvular heart disease |
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dose for non-depolarizing NMBS |
Rocuronium start dose at 0.45 mg/kg and then repeat bolus of 0.1-0.2 mg/kg or maintain continuous infusion of 10-12mcg/kg/m |
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reversal agent for non depolarizing neuromuscular blockers |
neostigmine .03 mg/kg to get TOF twitch ratio of 90% within 10-20m of administration |
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what is malignant hyperthermia? |
abnl Ca homeostasis
incr sensitivity of channel opening in response to activators rapid onset of extremely high fever with musc rigidity, precipitated by exogenous activators |
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what does malignant hyperthermia look like?
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what is look like rise in expiratoyr CO2 our of proportion to minutee ventiliaitno jaw contracnt tachycardia tachypenia venticla arrhythmia unstable BP incr temp |
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what are the skeletal musc relaxant |
dantrolene |
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MOA of skeletal musc relaxant |
blocks calcium at sarcoplasmic reticulum |
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what is Dantrolene used for |
-management of malignant hyperthermia( don't give to ppl all the time only if had this before) -prevention of malignant hyperthermia in susceptible individuals (preoperative/postoperative administration) -tx of spasticity associated with UMN disorders |
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what can you use with Dantrolene |
-IV sodium bicarb (may worsen hypercarbia) -hyperkalemia tx (dextrose, insulin, and diuresis- Furosemide) -antiarrhythmic, vasopressors, inotropes -is fever cool ASAP with ice packs and iced saline lavage of stomach and open body cavities |
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SE of Dantrolene |
-generalized muscle weakness: respiratory insufficiency, risk for aspiration PNA
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what drugs should in the cart?********* |
dantrolene (36 vials) sterile water for injection sodium bicarb dextrose 50% Ca cholride regular insuline amiodarone refrigerated, cold 0.9% sodium chloride injection |
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dose for skeletal muscle relaxant |
dantrolene 2.5 mg/kg IV push and repeat dose until sx subside or reach cumulative dose of 10mg/kg |
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MOA of general anesthesia |
cis loop receptor site increases effect of GABA also inhibits NE and 5HT |
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what tissues groups are vessel-rich that anesthesia works on |
brain, heart, kidney, liver, endocrine glands |
