Schmerler- Farm Exam 2

Front 1

Give MAC, blood gas, and oil gas coefficients of sevoflurane

Back 1

mac 2
bg 0.6
og 50

Front 2

Give MAC, blood gas, and oil gas coefficients of
isoflurane (forane)

Back 2

mac 1.15
bg 1.4
og 99

Front 3

Give MAC, blood gas, and oil gas coefficients of Nitrous Oxide

Back 3

mac 105
bg 0.47
og 1.4

Front 4

Give MAC, blood gas, and oil gas coefficients of desflurane (Suprane)

Back 4

mac 5.8
bg 0.42
og 18.7

Front 5

Give MAC, blood gas, and oil gas coefficients of Halothane (fluothane)

Back 5

mac 0.75
bg 2.3
og 224

Front 6

_____ is the only inorganic molecule in IAs.

Back 6

nitrous oxide

Front 7

Every IA is a _____ except for nitrous oxide.

Back 7

halogenated ether

Front 8

Halothane is avoided due to its side effect of

Back 8

hepatotoxicity (halothane hepatitis)

Front 9

Isoflurane is less toxic to patients because

Back 9

its surrounding fluorides make it resistant to metabolism

Front 10

Halogenating IAs helps to prevent

Back 10

flammability

Front 11

Halothane was designed to be a nonflammable anesthetic...however....a problem arises during metabolism because....

Back 11

Flouride is released into the body --> lipid peroxidation --> cell membrane damage and lysis

Front 12

The GABA receptor is a transmembrane receptor with an anion channel permeable to ____.

Back 12

Cl-

Front 13

GABA is composed of (#) protein subunits, and is the main _____ chemical in the brain.

Back 13

5, inhibitory

Front 14

List the types of things that can bind to the GABA receptor

Back 14

propofol, benzodiazepines, steroids, barbiturates, anesthetics/alcohol, picrotoxin

Front 15

The effects of general anesthetics and sedatives are mediated at different locations on the Gaba receptor, either by their ability to _____ the Gaba receptor channel directly or by ______ Gaba binding to potentiate Gaba responses.

Back 15

activate or gate,
modulating

Front 16

What site on the GABA receptor interacts with volatile anesthetics, alcohols, and etomidate?

Back 16

interface between second and third transmembrane segments

Front 17

What does it mean to be "gabamimetic"?

Back 17

drugs are inhibitory, increased Cl- flow into cell by changing shape and allowing entrance, Cl- makes cell more negative
gabamimetics are used for anesthesia

Front 18

Anesthesia causes a ______ depression of the CNS and ANS, causing loss of _____.

Back 18

dose dependent,
consciousness

Front 19

During anesthesia, cerebral O2 consumption/metabolic rate is ____. Therefore O2 requirement is _____.

Back 19

decreased and decreased

Front 20

Certain IAs will ____ intraocular pressure, which can damage the eyes. You may want to avoid volatile agents in these eye patients:

Back 20

decrease, glaucoma

Front 21

The only induction agent that increases Intra ocular pressure and therefore should not be used in glaucoma patients is

Back 21

ketamine

Front 22

IAs ____ intracranial pressure pressure that occurs from cerebral _____.

Back 22

increases, vasodilation

Front 23

Increased intracranial pressure from volatile agents can be counteracted by

Back 23

modest hyperventillation PaCO2 30-35

Front 24

All IV induction agents decrease ICP except

Back 24

ketamine (Will increase ICP)

Front 25

CPP=

Back 25

MAP-ICP

Front 26

When the brain can no longer compensate for increasing ICP, to avoid herniation you can do these things:

Back 26

give mannitol to diurese brain, drain CSF, decr amt of blood in brain by causing cerebral vasoconstriction with decr PaCO2, or improving cerebral venous drainage, surgically remove the tumor!

Front 27

The risk of increased CPP is

Back 27

brain ischemia

Front 28

Is it possible to pharmacologically manipulate the CSF compartment?

Back 28

no! the only way to manipulate size of compartment is drainage

Front 29

The fluid compartment can be manipulated by ____ and ____.

Back 29

steroids and diuretics

Front 30

This is the compartment most amenable to anesthesia intervention. It can be considered as these 2 separate components:

Back 30

blood compartment,
venous and arterial

Front 31

A _____ posture ensures better venous drainage to reduce ICP. Also circumferential pressure that increases ICP should be avoided in neuro cases, such as :

Back 31

head-up,
philadelphia collars, ETT ties

Front 32

Increased central venous pressure can be caused by

Back 32

PEEP, cardiac failure

Front 33

Anything that causes increased intrathoracic pressure can result in

Back 33

obstruction of cerebral venous drainage
(ex: kinked OETT, tension pneumothorax, coughing or straining against ETT, gas trapping in bronchospasm)

Front 34

It is important to maintain paralysis during craniotomies because

Back 34

suddent cough can result in dramatic herniation of cerebral structures through the craniotomy

Front 35

All IAs have these 3 qualities in common

Back 35

amnesiac in stage 1, decreased sensory and motor evoke potentials (SSEP), and are cerebral protective

Front 36

Des, sevo, and iso all cause vasodilation because they are depressants...this leads to

Back 36

increased cerebral blood flow and increased ICP

Front 37

The extent to which and IA causes increased ICP is

Back 37

dose dependent

Front 38

The main controller of cerebral tone that can be manipulated is

Back 38

PaCO2

Front 39

There are 5 cardiovascular mechanisms through which IAs decrease BP:

Back 39

1. CNS depression (depress vasomotor)
2. Direct cardiac depression (heart not beating as hard)
3. decreased systemic vascular resistance (vasodilation)
4. Baroreceptor depression (autoregulators for pressure depression causes decr BP)
5. hormonal changes such as decreased renin or vasopressin release (hormones and chemicals that maintain BP can be depressed and will drop BP)

Front 40

antiarrhythmic vs arrhythmogenic

Back 40

anti- depresses heart
arrythmo- stimulates heart

Front 41

All IAs have cardiovasc depression except:

Back 41

N20 -- will not affect BP!

Front 42

Halothane sensitizes myocardium to the effect of ____ such as epi, norepi and dopamine.

Back 42

catecholamines

Front 43

Describe the epi formulation and dose for incision injection site

Back 43

use 1:100,000 concentration (contains 0.01mg/mL)
can give 10 mL (0.1 mg) in 10 min
can give 30 mL in 1 hour (0.3 mg)

Front 44

Epi can be administered during IA use up to this dose

Back 44

no more than 5 mcg/kg

Front 45

epi 1:1,000 contains

Back 45

1 mg/1mL

Front 46

epi 1:10,000 contains

Back 46

0.1 mg/mL

Front 47

epi 1:100,000 contains

Back 47

0.01 mg/mL

Front 48

Halothane sensitizes the myocardium to ____, especially in this population:

Back 48

tachydysrhythmias, elderly

Front 49

During IA administration, the heart is more sensitive to

Back 49

catecholamines

Front 50

Describe coronary steal syndrome

Back 50

stealing blood delivery from other areas to feed to 3 main blood vessels in the heart

dilating resistance vessels in coronary circulation causes blood to be shunted away from coronary vessels supplying the ischemic zone -- creates more ischemia!

Front 51

Etomidate causes suppression of this endocrine organ:

Back 51

adrenal

Front 52

Anesthesia pre/post conditioning is anesthesia induced protection that occurs w all IAs because

Back 52

during ischemic preconditioning of the heart, the heart senses ischemic condition and prepares itself for next attack (12-24 hrs) by changing electrolyte and catecholamine levels (physiologic)

Front 53

Des and Iso cause tachycardia during induction due to ______, which is seen more commonly in _____ patients or when concentration is ______.

Back 53

respiratory irritation, young healthy patients, quickly increased

Front 54

_____ is best IA for preventing irritation from stinky/caustic gas.

Back 54

Sevoflurane

Front 55

The use of ____ protects against funtional and morphologic consequences of myocardial ischemia. -- better preservation of myocardial function and less myocardial damage

Back 55

IAs

Front 56

Cardioprotective effect of IA regimen is most consistent when

Back 56

agent is given throughout entire operation (before and during ischemia, and after reperfusion)

Front 57

This is the dose necessary for cardioprotective effects of sevo or des

Back 57

0.5 MAC

Front 58

Increasing dose on IA will have this influence on BP

Back 58

decreased BP with increased dose

Front 59

Significant tachycardia with increasing MAC is seen with

Back 59

desflurane

Front 60

In children, increased MAC will ____ HR.

Back 60

decrease

Front 61

_____ ANS is more prevalent in children, and _____ ANS is more prevalent in adults.

Back 61

sympathetic, parasympathetic

Front 62

The release of histamine will result in this respiratory effect

Back 62

bronchoconstriction

Front 63

All gas anesthetics bronchodilate except

Back 63

N20 - not strong enough

Front 64

All IAs cause a dose dependent resp depression except

Back 64

N20

Front 65

____ and ____ are resp irritants and may cause coughing during induction and emergence

Back 65

des and iso

Front 66

Opposite of opiates, IAs will depress _____ before ____.

Back 66

TV before RR

Front 67

Hypoxic pulmonary vasoconstriction (HPV)

Back 67

anesthetics depress in a dose dependent manner -- pharmacologic shunt -- less able to compensate for change in oxygenation, so must give at least 30% Fi02

Front 68

As IA dose increases, the pt becomes less responsive to this gas

Back 68

CO2

Front 69

What effect do IAs have on bronchi?

Back 69

relax- bronchodilation

Front 70

Kidneys still work while the patient is asleep and can respond to fluid challenges, however..

Back 70

response is slower and more depressed

Front 71

All anesthetics except N20 drop BP, having these subsequent renal effects:

Back 71

1. decr renal blood flow
2. decr GFR
3. decr urine output

Front 72

_____ is the only IA metabolized during anesthesia, the others are only metabolized in trace amounts.

Back 72

sevo- metabolized 5-8%

Front 73

Due to the free fluoride ion release in sevo administration, it should be avoided in these patients

Back 73

renal patients

Front 74

2 potential toxic substances that are produced by sevo are

Back 74

compound A and the free fluoride ion

Front 75

Plasma fluoride during and after sevo administration is greater in this pt population

Back 75

obesity

Front 76

What is TIVA and what population should you definitely give it to?

Back 76

Total IV anesthesia - use for Malignant hyperthermia patients (can also give n20)

Front 77

3 factors that make someone prone to MH

Back 77

family history/genetics (test w halothane contracture test prior to admin)
hx of trismus (inability to open mouth normally)
hx of contractures and transient incr temp after exercise

Front 78

Between IAs and IV induction drugs, which are more predictable and easier to titrate?

Back 78

IAs

Front 79

2 potential toxic substances that are produced by sevo are

Back 79

compound A and the free fluoride ion

Front 80

Plasma fluoride during and after sevo administration is greater in this pt population

Back 80

obesity

Front 81

What is TIVA and what population should you definitely give it to?

Back 81

Total IV anesthesia - use for Malignant hyperthermia patients (can also give n20)

Front 82

3 factors that make someone prone to MH

Back 82

family history/genetics (test w halothane contracture test prior to admin)
hx of trismus (inability to open mouth normally)
hx of contractures and transient incr temp after exercise

Front 83

Between IAs and IV induction drugs, which are more predictable and easier to titrate?

Back 83

IAs

Front 84

_____ are most susceptible to MH

Back 84

children - bc of no previous exposure

Front 85

Epi breaks down into ____, which breaks down into _____.

Back 85

dopamine, tyrosine

Front 86

Meperidne breaks down into normeperidine, which has thes effects

Back 86

lowers seizure threshold and increases temp

Front 87

How do IAs affect GI function?

Back 87

dose dependent decrease in function -- decr peristalsis and gastric emptying

Front 88

Halothane is famously not used anymore bc of this nasty little side effect

Back 88

halothane hepatotoxicity

Front 89

All IAs are capable of triggering this bad news syndrome and are absolutely contraindicated if pt has a history of it, except for N20.

Back 89

MH

Front 90

N20 inhibits this enzyme, leading to immune suppression due to Vit B12 depression.

Back 90

methionine synthetase

Front 91

What effect does N20 methionine synthetase have on DNA/RNA

Back 91

depresses protein synthesis

Front 92

This metabolite of sevo has more free radicals, toxic metabolites.

Back 92

free fluoride ion

Front 93

Is n20 teratogenic?

Back 93

hell yes.

Front 94

All IAs relax the uterus, and the low concentrations used during c-sections may cause...

Back 94

incr uterine bleeding

Front 95

All anesthetics except ___ can be used during pregnancy. Administration of IAs during pregnancy is associated with increased risk of:

Back 95

N20, post-op. miscarriage

Front 96

Emergence delirium is more common in this population, and is demonstrated with this sign ____.

Back 96

children,
restless behavior

Front 97

Emergency delirium may delay discharge, and is treated with:

Back 97

reducing pre op anxiety, removing post op pain, providing quiet pacu environment, give a little fentanyl or versed

Front 98

This is the type of renal failure that arises from free fluoride ion release

Back 98

polyuric

was commonly seen in methoxyflurane (penthrane)

Front 99

Compound A

Back 99

derived from Sevoflurane use, occurs inside anesthesia machine, only occurs w certain brands of soda lime, and is hepato and nephro toxic

Front 100

____ is associated with greater compound A production.

Back 100

baralyme

Front 101

CO is dangerous because it displaces ____ from hemoglobin, creating ____, which is 250x more affinity for binding hgb than 02.

Back 101

oxygen, carboxyhemoglobin

Front 102

The difficulty with monitoring CO levels arises from

Back 102

pulse ox does not distinguish between carboxyhemoglobin and oxyhemoglobin

Front 103

This IA produces the greatest amt of CO when it goes through CO2 absorbent.

Back 103

desflurane

Front 104

Methods to decrease CO in the circuit

Back 104

soda lime instead of baralyme, fresh absorbent, avoiding techinques that dehydrate absorbent (Can add water as last resort to absorbent cannister)

Front 105

How does increasing flow affect Compound A production?

Back 105

decreases it!

Front 106

3 ways providers can be exposed to IAs via leaks

Back 106

masks, high-pressure fittings, and exhalation valves

Front 107

This area has the highest concentration of environmental IAs

Back 107

PACUs and dental suites

Front 108

The critical period of organ development for the fetus is

Back 108

31-71 days since first day of last menses

Front 109

Anesthesia risks during pregnancy depend on

Back 109

anatomic and physiologic changes (difficult intubation, aspiration), and underlying maternal disease

Front 110

Fetal risks associated with surgery include

Back 110

fetal loss, preterm labor, growth restriction, and low birth weight

Front 111

The anesthetic management of the pregnant surgical patient should focus on avoiding these 4 situations

Back 111

hypoxemia, hypotension, acidosis, and hyperventillation

Front 112

This IA has the fastest recovery due to its low blood gas coefficient

Back 112

desflurane

Front 113

What are the advantages of N20?

Back 113

moderate analgesia (15 mg IV morphine)
rapid uptake and elim.
little cardiac/resp depression
nonpungent
allows less use of more potent coadministered anesthetic

Front 114

What are the disadvantages of N20?

Back 114

expansion of closed air spaces
requires high concentration
immune suppression
teratogenic (but can be used during c-section)

Front 115

What are the advantages of isoflurane?

Back 115

minimal biotransformation
maintains cardiac output due to vasodilation
inexpensive

Front 116

What are the disadvantages of isoflurane?

Back 116

pungent odor
airway irritant

Front 117

What are the advantages of desflurane?

Back 117

rapid uptake and elim.
stable molecules
minimal biotransformation

Front 118

What are the disadvantages of desflurane?

Back 118

airway irritant
low boiling point
sympathetic stimulation causing tachycardia
expensive

Front 119

What are the advantages of sevoflurane?

Back 119

rapid uptake and elim.
nonpungent

Front 120

What are the disadvantages of sevoflurane?

Back 120

susceptible to biotransformation (metabolized 5-8%)
reacts w soda lime to produce compound A
increases serum fluoride concentration
expensive

Front 121

N20 inhibits ____ to suppress immunity. Without this, protein synthesis with vitamin ____ is inhibited, which is necessary for ____ synthesis.

Back 121

methionine synthetase,
B12,
purine

Front 122

Pts at risk for B12 deficiency:

Back 122

nutritional disorders (elderly, vegans, alcoholics)
malabsorption (prolonged use of PPIs or H2 antagonists, pernicious anemia, atrophic gastritis post-gastrectomy, whipple procedure, ileal resection, crohns disease)
infection (bacterial overgrowth, tapeworm)

Front 123

Absolute contraindications for N20 use

Back 123

- known deficiency of enzyme or substrate in meth synthetase pathway
- potential toxicity from gas filled space expansion (emphysema, pneumothorax, middle ear sx, pneumocephalus, air embolus)
- raised ICP

Front 124

Relative contraindications for N20 use

Back 124

-pulm HTN
-anesthesia > 6 hrs
-first trimester of pregnancy
-high risk post-op N/V

Front 125

How long does it take for N20 to clear?

Back 125

3-5 min (faster than other IAs)

Front 126

Because of its amnestic and analgesic properties, as well as capability to lower requirements of costly other anesthetic drugs, ____ is a commonly used IA.

Back 126

N20

Front 127

____ is rapidly eliminated, resulting in faster recovery even w use of inhaled anesthetics w higher lipid solubility in short procedures in elderly pts.

Back 127

N20

Front 128

___ was the first nonflammable/nonexplosive drug, making it highly used until its negative side effects became evident, which involved post-op liver failure mimicking hepatitis.

Back 128

Halothane,
causes lethargy, incr liver enzymes, jaundice and hepatomegaly)

Front 129

Contributing factors to halothane hepatotoxicity

Back 129

immune mediated, female sex, hypoxia, pharmacogenetics, multiple exposures, pre-existing condition, halothane metabolism, obesity, incr enzyme induction, age, reduced hepatic perfusion, history of allergy/eczema

Front 130

Using ____ during rapid increases in dose during induction has greater effect to incr BP and HR, which can be minimized by co-admin of ____.

Back 130

Desflurane, fentanyl

Front 131

IA preconditioning

Back 131

- protects heart
- incr cerebral PaO2 and decr danger of brain injury
- protects against coronary artery occlusion

Front 132

Even though pt may appear alert or talking, pharyngeal dysfunction persists until ___MacAwake.

Back 132

0.25

Front 133

What determines recovery speed?

Back 133

anesthetic elimination and anesthetic level permitting wakefulness (MacAwake)

Front 134

MacAwake

Back 134

concentration at which 50% of patients appropriately obey commands and can maintain airway
- greatest in N20

Front 135

In order to reduce the risk of aspiration during emergence, you can perform a deep extubation under propofol and non-morphine opioid, and tube should be removed while...

Back 135

lungs are fully inflated!!

Front 136

What are risk factors for nausea?

Back 136

youth, female, opioid and N20 use, relaxant antagonism (neostigmine), incr fluids or colloids given

Front 137

You have to use multiple drugs to manage nausea because this sensation is

Back 137

mediated by several different neurotransmitters

Front 138

IA effects on brain

Back 138

incr CBF, incr ICP, decr cerebral metabolic rate

Front 139

IA effects on lungs

Back 139

incr RR, decr TV, incr PaO2, bronchodilate

Front 140

IA effects on kidneys

Back 140

decr RBF, decr GFR, decr U/O

Front 141

IA effects on vasculature

Back 141

decr BP, decr SVR, vasodilate

Front 142

N20 effects on bone marrow

Back 142

inhibits, immunosuppression

Front 143

IAs effects on liver

Back 143

decr hepatic blood flow, halothane hepatitis

Front 144

IAs efect on muscles

Back 144

muscle relaxation

Front 145

IAs effects on heart

Back 145

decr CO, incr CVP

Front 146

Natural ____ haired people require increased MAC on IAs to prevent movement.

Back 146

red

Front 147

The potency of general anesthetics correlates with their _____, indicating the importance of their interaction with hydrophobic targets.

Back 147

solubility in oil

Front 148

IAs enhance inhibitory synaptic transmission postsynaptically by ______, extrasynaptically by _______, and presynaptically by _____.

Back 148

postsynapse: potentiating ligand-gated ion channels activated by GABA and glycine; inhibit excitatory ionotropic receptors activated by glutamate
extrasynapse: enhancing GABA receptors and leak currents
presynapse: enhancing basal GABA release, inhibit glutamate release

Front 149

Uptake from lungs is the product of 3 factors:

Back 149

1. blood solubility
2. cardiac output
3. partial pressure driving anesthetic from one phase (lung) into second phase (venous blood)

Front 150

Lower solubility= _____ recovery

Back 150

faster

Front 151

_____ is an important mechanism by which pulm blood is preferentially redistributed away from poorly ventillated lung regions to those w adequate alveolar ventilation.

Back 151

hypoxic pulmonary vasoconstriction (HPV)

Front 152

IAs reduce ____ and ____ and cause tachypnea in a dose-related fashion.

Back 152

TV and minute ventillation

Front 153

All IAs depress the ventillatory responses to hypercapnia and hypoxia by altering the central and peripheral ______ function in a dose-dependent fashion.

Back 153

chemoreceptor

Front 154

The combination of drug-related antibodies, apparent need for prior sensitization, and association of fever and eosinophilia all support an ____ basis for anesthetic-induced hepatitis,

Back 154

immune

Front 155

New calcium hydroxide based CO2 absorbents prevent the formation of these 2 nasty byproducts

Back 155

carbon monoxide, compound A

Front 156

_____ boils at room temp, and comes specially packaged so it cant be opened and anesthetize the surrounding environment.

Back 156

Desflurane

Front 157

Occupational exposure to high concentrations (10^3 ppm) may be correlated with increased incidence of...

Back 157

abortions, decr fertility; if b12 deficient, may be at risk from neuro injury from N20

Front 158

Mac of desflurane is ____ w age.

Back 158

decreases

Front 159

Due to additive effect, if des is given w _____, less des is required.

Back 159

N20

Front 160

MAC requirement peaks at this age

Back 160

6 months old

Front 161

The hemodynamic response to desflurane during maintenance anesthesia (incr BP and HR) is....

Back 161

transient,
dose not occur in everybody,
treatment not usually needed due to brief duration

Front 162

How to counteract hemodynamic changes w des:

Back 162

- IV opioid prior to incr concentration of des
- initial vaporizer setting 3-6%
- incr or decr in 1% increments
- use of short acting beta blocker (esmolol)

Front 163

IAs ____ heat loss.

Back 163

increase

Front 164

Glucose levels _____ during surgery, with a simultaneous release of _____. This is a normal part of the stress response, and these levels return to normal shortly after surgery.

Back 164

increase, insulin

Front 165

It is helpful that with increasing MAC of IAs, there is a dose dependent ____ in O2 consumption.

Back 165

decrease

Front 166

If a patient is spontaneously breathing during IA administration, they are likely to retain ___

Back 166

CO2

Front 167

Narcotics used during anesthesia cause a release in ADH, which will

Back 167

decrease urine output.

Front 168

What does low temp do to MAC?

Back 168

The colder the patient, the less MAC required to put them to sleep

Front 169

List the vapor pressures of des, sevo, iso, N20

Back 169

sevo- 157 (hardest to vaporize)
des- 669
iso- 238
N20- 38,770

Front 170

What does low temp do to MAC?

Back 170

The colder the patient, the less MAC required to put them to sleep

Front 171

List the vapor pressures of des, sevo, iso, N20

Back 171

sevo- 157 (hardest to vaporize)
des- 669
iso- 238
N20- 38,770

Front 172

What is the trade name for flamzenil and what does it do?

Back 172

romazicon,
benzo reversal agent

Front 173

What is the drug in the butyrophenone class used as an anti-emetic?

Back 173

droperidol (inapsine)

Front 174

What is the trade name for etomidate?

Back 174

amidate
induction agent

Front 175

What is fospropofol and when is it used?

Back 175

trade name lusedra, is a propofol substitute that is less potent and is water soluble, best for continuous gtt rather than induction

Front 176

What are the 2 main barbiturates that were recently removed from the market?

Back 176

thiopental (pentothal)
methohexital (brevital)

Front 177

What is a thiobarbiturate?

Back 177

sedative, contain a sulfur molecule at C-2, anesthesia use, thiopental (pentothal)

Front 178

What is an oxybarbiturate?

Back 178

sedative, contains an oxygen molecule at C-2, phenobarbital is long-acting, pentobarbital and secobarbital are shorter acting, used for anti-seizure medication

Front 179

When is an n-methyl barbiturate?

Back 179

contains a methyl group attached to the Nitrogen molecule at N-1 or N-3, methohexital (Brevital), anesthesia use

Front 180

What are the ultra short and short acting barbiturates?

Back 180

ultra short- thiopental and methohexital
short- pentobarbital, secobarbital

Front 181

What is the long acting barbiturate?

Back 181

phenobarbital (luminal)

Front 182

What is the alpha distribution half life?

Back 182

time it takes to go into the body, a less important clinical #

Front 183

What is the beta elimination half life?

Back 183

how long it takes to eliminate drug from ody, more important clinical #
if half life = 12 hrs, multiply by 4 -- it takes 48 hrs for thiopental to go away
propofol has a 1 hr half life, takes 4 hrs to get out of body (causing euphoria with minimal hangover)

Front 184

The diazepam metabolite can hang out in the body for...

Back 184

4 days! yikes!

Front 185

Half life (is/is not) synonymous with duration of action

Back 185

is NOT!!!

Front 186

Duration of action is determined by

Back 186

where the drug is in the body -- is it near the receptors it acts on?

Front 187

What is the significance of protein binding?

Back 187

if drug is bound to a nonreceptor protein, it cannot take action -- only free unbound drug can act on receptors

Front 188

Only 2% of propofol can bind to receptors that put you to sleep, 98% is bound to albumin and AAG.... BUT, what happens if you have low albumin level?

Back 188

drug will bind less to circulating protein and more available/free to act on receptor -- the same dose becomes more potent!

Front 189

What are the 4 populations likely to have low proteins?

Back 189

malnourished,
end stage liver dz,
end stage renal dz,
last trimester of pregnancy (due to fluid shifts)

Front 190

What happens when you co-administer 2 highly protein bound drugs to a pt w fixed amt of albumin?

Back 190

one will have a greater action due to less protein binding in plasma, causing a drug interaction!!

Front 191

It is ideal for induction drugs to have a ____ half-life.

Back 191

shorty!

Front 192

If a drug is <90% protein bound, then it is....
If a drug is >90% protein bound, then it is...

Back 192

<90% - not bound enough for interaction
>90% - may cause drug interaction to incr its effects and plasma levels of drug

take home point: low protein binding means it is unlikely to cause an interaction!!

Front 193

Which IV anesthetic agent has the longest and shortest half life?

Back 193

longest- diazepam, 20-40 hrs!
shortest- propofol, 1-3 hrs!

Front 194

What is the elimination half life of lorazepam?

Back 194

10-20 hrs

Front 195

What is the elimination half life of midazolam?

Back 195

2-4 hrs

Front 196

What is the elimination half life of etomidate?

Back 196

2-5 hrs

Front 197

What is the elimination half life of ketamine (ketalar)?

Back 197

2-3 hrs

Front 198

What is the protein binding % of diazepam, lorazepam, and propofol?

Back 198

all 98%!

Front 199

What is the protein binding % of midazolam?

Back 199

94%

Front 200

What is the protein binding of etomidate?

Back 200

75%

Front 201

What is the protein binding of ketamine?

Back 201

12%!

Front 202

This is the time necessary for the plasma content of a drug to drop to half of its prevailing concentration after rapid bolus injection

Back 202

elimination half life (t 1/2)

Front 203

A drug is regarded as being fully eliminated when approx ___% has been eliminated from the body. Blood level is = to ____ level.

Back 203

95%, receptor level

Front 204

What is first-order kinetics? (aka dosage dependence)

Back 204

most drugs leave hte body at a constant rate or percentage over time -- this is the reason why half life is constant!

Front 205

Zero-order elimination

Back 205

a constant amount (not a percentage) is eliminated over time, (phenytoin), which are dose dependent and follow zero order at high doses and first order once drug levels have fallen

Front 206

Describe first, second and third half life % for drug eliminated and remaining

Back 206

1- 50% elim 50% remain
2- 75% elim 25% remain
3- 87.5% elim 12.5 remain

half life is constant, keep dividing by 2 to find out how long it takes to get rid of drug

Front 207

What are the 2 proteins that bind basic drugs?

Back 207

albumin and
alpha 1 acid glycoprotein (AAG)

Front 208

Both protein deficiency and co-admin of 2 highly protein bound drugs leads to

Back 208

drug interactions

Front 209

Albumin can bind neutral, acidic or basic drugs, but it favors

Back 209

acidic drugs

Front 210

AAG and beta globulin favor binding to

Back 210

basic drugs

Front 211

The degree of protein binding for a drug is proportional to its ____ .

Back 211

lipid solubility

the more lipid soluble, the more highly protein bound it tends to be

Front 212

Protein binding can be overcome by _____, and the bond between drug and protein is usually _____.

Back 212

adding more drug, weak

Front 213

Extensive protein binding slows drug

Back 213

elimination (metabolism and excretion by glomerular filtration)

Front 214

What are the 4 possible interactions that free drug can have?

Back 214

1. tissue binding
2. bound drug to protein
3. receptor binding
4. elimination

Front 215

Propofol will redistribute from brain to muscles and fats within ___ minutes.

Back 215

15 minutes

Front 216

Within the first minute of propofol admin, there is only ___% left in the blood, and __% will be in the vital organs. It is lipid soluble and will go to the ____ organs first.

Back 216

20%, 60%, vital

Front 217

Onset of action after injecting propofol until nightnight is

Back 217

15 seconds

Front 218

Peak propofol effect is in ____ minute(S)

Back 218

1 minute

Front 219

The half life of propofol is ___ hour(s) and remains in the body for ____ hour(s).

Back 219

1 hour, 4 hours

Front 220

Propofol has a rapid _____ to the brain and a rapid _____ to the peripheral tissues.

Back 220

distribution, redistribution

Front 221

All IV anesthetic drugs are gabamimetic except for ____ and ____.

Back 221

ketamine and precedex

gabamimetic drugs open Cl- channels and inside of cell becomes more negative, making it harder to fire nad causing a depression

Front 222

Ketamine is an (Agonist/antagonist) of the ____ receptor.

Back 222

antagonist, NMDA receptor (n-methyl-d-aspartate receptor)

Front 223

What neurotransmitter does ketamine block?

Back 223

glutamate, which normally stimulates/excites

Front 224

All benzos share a basic ____ structure

Back 224

3-ring

Front 225

Benzos are used for these 3 things

Back 225

low dose anti-anxiety
moderate dose anti-anxiety and amnesia
high dose sedation and sleep - anxiolytic and amnestic

Front 226

Later generations (There are 4 total) of benzos are safer that previous ones because

Back 226

they have a shorter half life, making them more predictable

Front 227

Non benzo receptor agonists (NBRAs) are gabamimetic, and serve this purpose

Back 227

sleeping pills,
sonata, lunesta, ambien


rozarem is a melatonin receptor agonist sleeping pill

Front 228

What is unique about the injection of etomidate, diazepam and propofol, and how can it be avoided?

Back 228

pain on injection, premedicate with IV lidocaine

Front 229

What is the class of drugs containing propofol and fospropofol?

Back 229

alkylphenols

Front 230

Why is the lipid emulsion that propofol is prepared in risky business?

Back 230

it ust be handled very carefully because it is highly susceptible to bacterial growth inside the solution (EDTA content retards bacterial growth)

Front 231

Some propofol brands contain sulfites, which can be bad for thes populations of pts

Back 231

sulfite hypersensitivity, asthmatic pts

Front 232

What are the 2 proteins that bind basic drugs?

Back 232

albumin and
alpha 1 acid glycoprotein (AAG)

Front 233

Both protein deficiency and co-admin of 2 highly protein bound drugs leads to

Back 233

drug interactions

Front 234

Albumin can bind neutral, acidic or basic drugs, but it favors

Back 234

acidic drugs

Front 235

AAG and beta globulin favor binding to

Back 235

basic drugs

Front 236

The degree of protein binding for a drug is proportional to its ____ .

Back 236

lipid solubility

the more lipid soluble, the more highly protein bound it tends to be

Front 237

The ___ of eggs is usually used in drugs, and pts with egg allergy are usually allergic to egg ____. People with egg allergy are also often allergic to ___ and ___.

Back 237

yolk in drugs, whites in allergies,
peanuts and soy

Front 238

What is a prodrug?

Back 238

an inactive pharmacological substance that once administered, is metabolized in vivo into the active compound -- rationale for use is that it optimizes pharmacokinetics, improved bioavailability

Front 239

What are the induction and maintenance doses of fospropofol (lusedra)?

Back 239

induction- 6.5 mg/kg
maint- 1.6 mg/kg

decrease 75% in elderly

Front 240

What are the unique side effects of fospropofol and its special location?

Back 240

parathesia and pruritis in groin!
hypoxemia and hypotension

Front 241

This IV induction drug produces significant myoclonus

Back 241

etomidate- excitatory

also ketamine to some extent

Front 242

What is the induction dose, onset, and duration of propofol?

Back 242

induction - 2 mg/kg
onset <30 sec
duration 3-8 min

Front 243

What is the induction dose, onset, and duration of fospropofol?

Back 243

induction - 6.5 mg/kg
onset 5-15 min
duration 20-45 min

Front 244

What is the induction dose, onset, and duration of etomidate?

Back 244

induction - 0.3 mg/kg
onset <30 sec
duration 5-10 min

Front 245

What is the induction dose, onset, and duration of diazepam?

Back 245

induction - 0.3-0.6 mg/kg
onset 45-60 sec
duration 15-30 min

Front 246

What is the induction dose, onset, and duration of lorazepam?

Back 246

induction- 0.03-0.06 mg/kg
onset 60-120 sec
duration 60-120 min

Front 247

What is the induction dose, onset, and duration of midazolam?

Back 247

induction - 0.2-0.4 mg/kg
onset 30-60 sec
duration 15-30 min

Front 248

What is the induction dose, onset, and duration of ketamine?

Back 248

induction - 2-4 mg
onset 45-60 sec
duration 10-20 min

Front 249

Brain metabolism and blood flow are _____.

Back 249

proportional,
as one goes up/down, so does the other

Front 250

Administration of etomidate is associated with regional reductions in blood flow, and this can exacerbate...

Back 250

ischemic brain injury

Front 251

Cerebral blood flow and CMR02 are decreased in all IV induction drugs except

Back 251

ketamine

Front 252

Which IV induction agent is most and least cardiac depressing? Which is a cardiac stimulant?

Back 252

most- propofol
least- etomidate
stimulant- ketamine (incr BP and HR)

Front 253

Propofol is pretty much indicated all of the time unless...

Back 253

CV instability, sulfite allergy -- if so, use etomidate or ketamine (in cases of trauma, shock, decr BP)

Front 254

Of the 5 mechanisms for decreased BP from IV induction agents, these 2 are the most significant according to Johnny:

Back 254

decr SVR (vasodilation) and
baro-receptor depression

Front 255

Which IV induction drug is the most and least resp depressing?

Back 255

most- propofol
least- ketamine

Front 256

Respiratory benefits of ketamine include

Back 256

maintain airway reflexes and RR, significant bronchodilator (good to use in actively wheezy pts)

Front 257

Ketamine stimulates a release of which neurotransmitters in the body?

Back 257

catecholamines (Epi/norepi)

Front 258

If pt has asthma but is not actively wheezing, whats the IV induction agent of choice?

Back 258

propofol!

Front 259

Johnny says these 3 enzymes cause side effects of IV anesthetics:

Back 259

1. methionine synthetase: inhibitied by N20, immune suppression, teratogenic, interruption of DNA/RNA synthesis
2. etomidate inhibits 11 beta hydroxylase, causes adrenal suppression, decr cortisol and aldosterone release
3. Etomidate stimulates ALA synthetase, causing porphyria (abd pain, blisters, seizures, bad news bears)

Front 260

Can propofol cross the placental barrier?

Back 260

yes- baby may be depressed initially but this is only temporary

Front 261

Propofol Infusion Syndrome (PRIS)

Back 261

more of a critical care issue than anesthesia; occurs only after continuous infusion over several days; related to the fact that propofol is a lipid emulsion; fatal syndrome w cardiac dysrhythmia and collapse, metabolic acidosis, ARF, rhabdomyolysis, hypotension, widened QRS, asystole

Front 262

Who is at greatest risk for PRIS?

Back 262

young age, high dose > 4-5 mg/kg/hr, duration > 48 hrs, critical illness, high fat low carb intake, co-admin of catecholamine infusion or steroids, problems w mitochondrial fatty acid oxidation

Front 263

How do you treat PRIS?

Back 263

stop propofol, (duh!)
improve gas exchange,
cardiac pacing if bradycardia,
phosphodiesterase inhibitors,
glucagon,
ECMO,
CRRT

Front 264

These are the CNS effects of IV anesthetics that are ALL depressed except ketamine:

Back 264

decr in
CBF, CPP, CMRO2, ICP, IOP

Front 265

This IV anesthetic has no cardiac effects to depress or stimulate

Back 265

etomidate

Front 266

What does it mean that ketamine is a dissociative anesthetic?

Back 266

blocks ability of one are aof the brain to communicate w the other

Front 267

Ketamine is a derivative of _____. It increases these neuro values:

Back 267

PCP, increased CMRO2, CBF, ICP

Front 268

What effect does ketamine have on your peepers?

Back 268

nystagmus and increased IOP

Front 269

___ is the best IV anesthetic for analgesia

Back 269

ketamine

Front 270

Ketamine causes this SNS effect?

Back 270

sympathomimetic

Front 271

Even though ketamine generally maintains airway reflexes and respirations, it may ...

Back 271

have a period of initial apnea w high dose/rapid induction

Front 272

_____ increases resp secretions, salivation, and muscle tone.

Back 272

ketamine

Front 273

This IV agent has psychomimetic effects of emergence delirium, nightmares and hallucinations, which can be treated with waking pt in a dark and calm environment and coadmin of benzos.

Back 273

ketamine

Front 274

Ketamine admin should be used with caution in these populations

Back 274

HTN, angina, CHF, incr ICP, (neuro pts), incr IOP, psych dz, airway problems

Front 275

What is the induction dose, maintenance, sedation/analgesia dose, and preventive analgesia doses of ketamine?

Back 275

induction 2 mg/kg or 6 mg/kg IM/ORAL
maint- 1 mg/kg IV (half induction dose q30 min)
sedation/analgesia- 25-50 mg over 2-3 min (.2-.8 mg/kg)
preventive analgesia- .25 mg/kg IV, usually 25 mg/dose increments

Front 276

Why is ketamine so damn convenient?

Back 276

it can be given IV, IM, PO

Front 277

Clinical indications for ketamine as IV agent:

Back 277

1. induction in high risk pts (Very sick and unstable)
2. obstetrics (induction or low dose analgesia)
3. adjunct to local and regional anesthetic techniques
4. outpt surgery
5. outside OR for minor/procedural reasons

Front 278

Why does it suck that etomidate blunts cortisol release and steroidgenesis in the body if used during surgery?

Back 278

cortisol has many protective functions in the body when under stress

Front 279

Do any IV anesthetics affect liver function tests?

Back 279

NOPE

Front 280

Which is the only IV agent that might increase RBF?

Back 280

ketamine (propofol decreases RBF!)

Front 281

What is a nice alternative to etomidate to avoid adrenal suppression and speed recovery?

Back 281

its prodrug, moc-etomidate

Front 282

Whats the difference between retrograde and anterograde amnesia? Which is easier to achieve??

Back 282

retrograde- something painful/unpleasant occurs and then give drugs after to wipe out memory, only possible in 30-40 % of patients
anterograde- give pt drug first, then perform unpleasant/painful stim, possible in 75% of pts

Front 283

What drug class is best for achieving anterograde amnesia?

Back 283

benzos- particularly versed

Front 284

Which IV anesthetic is most likely to make you puke, and which is actually an anti-emetic?

Back 284

puke likely- etomidate (and ketamine)
puke helper- propofol

Front 285

Although benzos in general arent anti-emetics, during chemo-induced N/V (CINV), this benzo is useful

Back 285

ativan

Front 286

Induction movement is mostly likely after giving this IV agent

Back 286

etomidate

Front 287

_____ increases resp secretions, salivation, and muscle tone.

Back 287

ketamine

Front 288

This IV agent has psychomimetic effects of emergence delirium, nightmares and hallucinations, which can be treated with waking pt in a dark and calm environment and coadmin of benzos.

Back 288

ketamine

Front 289

Ketamine admin should be used with caution in these populations

Back 289

HTN, angina, CHF, incr ICP, (neuro pts), incr IOP, psych dz, airway problems

Front 290

What is the induction dose, maintenance, sedation/analgesia dose, and preventive analgesia doses of ketamine?

Back 290

induction 2 mg/kg or 6 mg/kg IM/ORAL
maint- 1 mg/kg IV (half induction dose q30 min)
sedation/analgesia- 25-50 mg over 2-3 min (.2-.8 mg/kg)
preventive analgesia- .25 mg/kg IV, usually 25 mg/dose increments

Front 291

Why is ketamine so damn convenient?

Back 291

it can be given IV, IM, PO

Front 292

What is myoclonia?

Back 292

phenomena during induction of involuntary mvmts due to uneven distribution of drug into brain -- twitching, temporary

Front 293

What is the infusion dose range of propofol?

Back 293

25-200 mcg/kg/min

Front 294

All induction agents are metabolized ______, and elimination starts with initial ______, then breaks down into ____ and ____ metabolites.

Back 294

hepatically, redistribution,
nonactive and active metabolites

Front 295

What are the goals of managing anaphylaxis during anesthesia?

Back 295

1. correct arterial hypoxemia
2. restore intravasc fluid volume
3. inhibit further release of chemical mediators

Front 296

What is immediate mgmt of anaphylaxis during anesthesia?

Back 296

stop admin of agents likely to cause it,
call for help,
maintain airway w 100% Fi02,
elevate legs,
give epi IV 1:10,000 0.5-1 mL over 1 min (never give undiluted IV),
give fluid bolus (colloid PRN)

Front 297

What is the secondary mgmt of anaphylaxis during anesthesia?

Back 297

1. antihistamine infusion
2. corticosteroid IV
3. bronchodilators (if bronchospasm)

Front 298

What drug class is dexmedetomidine?

Back 298

nonselective presynaptic alpha 2 agonist

Front 299

What effect does precedex have on CNS receptors?

Back 299

sympatholysis, sedation, antinociception, anti-shivering

Front 300

Precedex offers ____ sedation, making the pt _____ arousable, and has a ____ duration fo action.

Back 300

lighter, easily, shorter

Front 301

Precedex is helpful in _____ cases when you might need to wake up pt to assess neuro fcn (wake up test).

Back 301

neuro cases

Front 302

Limited resp depression in precedex use makes for a _____ margin of safety.

Back 302

BIG N WIDE!!

Front 303

Alpha 2 agonists like precedex act through the ____ pathways to exert their sedative effects.

Back 303

endogenous sleep-promoting

Front 304

Routes for precedex admin

Back 304

intrathecal/epidural, IV

Front 305

Even though precedex reduced minute ventilation, it retains

Back 305

ability to respond to incr CO2 (similar to natural sleep patterns)

Front 306

How does precedex affect CV system?

Back 306

decr HR, BP, SVR, CO, nad myocardial contractility

Front 307

When is precedex best indicated?

Back 307

short term sedative for adult intubated pts in ICU (anxiolysis, sedation, analgesia, sympatholysis); premedication for anesthesia, maintenance of anesthesia

Front 308

What is a common complaint of precedex pts?

Back 308

dry mouth

Front 309

Providers/hospitals don't use precedex as much because...

Back 309

its expensive as hell! (approx $500/case!)

Front 310

What are the induction and infusion doses of precedex?

Back 310

initial: 1 mcg/kg over 10 min
maint: 0.2-0.7 mcg/kg/hr

Front 311

Precedex has some unpleasant CV side effects, but may reduce hospital stays because

Back 311

it causes less delirium

Front 312

Postsynaptic alpha 2 receptor agonists are _____, whereas presynaptic alpha 2 receptor agonists are _____.

Back 312

sympathomimetic,
sympatholytic

Front 313

_____ is safest in ability to reduce ICP.

Back 313

propofol

Front 314

_____ can also be used in conjunction to reduce ICP during anesthesia, but the provider must beward to prevent hypovolemia!

Back 314

mannitol

Front 315

What does johnny like best for induction unless otherwise contraindicated?

Back 315

propofol!!

Front 316

what does johnny like best for maintenance unless otherwise contraindicated?

Back 316

propofol!! (could use des and sevo, but may require longer recovery and more pukes)

Front 317

Early recovery and emergence is faster using this IA, but transfer to phase 2 anesthesia is faster with this IA.

Back 317

desflurane, sevoflurane

Front 318

Which is preferable? IV or IA induction?

Back 318

Johnny says IV!

Front 319

Propofol decreases both ____ and ____ in the heart, and blunt the _____ reflex.

Back 319

preload, afterload, barostatic

results in slower HR!

Front 320

Etomidate is capable of inhibiting 11 beta hydroxylase for up to ____hours!

Back 320

12

Front 321

____ patients are more sensitive to ventilatory depression with midazolam and propofol.

Back 321

COPD

Front 322

The best anti-emetics are _____ blockers.

Back 322

dopamine

Front 323

Why is it hard to assess anesthetic depth with ketamine?

Back 323

pts might be snowed but are still moving, talking, opening eyes, tracking gaze

Front 324

Ketamine is notorious for causing this type of secretion increase?

Back 324

slobbering and drooling and salivating! oh my!

Front 325

This drug is the agent of choice in a pt actively wheezing

Back 325

ketamine

Front 326

Anything that blocks dopamine can cause these effects:

Back 326

EPS (extrapyramidal effects)
parkinson-like, fine tremors, parkinson shuffle

Front 327

Don't be giving Parkinson's patients these 2 kinds of drugs!

Back 327

droperidol and reglan, both block dopamine

Front 328

Precedex is sympatholytic but does not produce true anesthesia, so...

Back 328

it must be used in conjunction w another drug

Front 329

porphyria

Back 329

genetic or acquired inability to handle production of hgb in the body, porphyrins compose heme, pts cant control how many porphyrins are produced

Front 330

acute vs non acute porphyrias

Back 330

acute- enzyme inducible (acute intermittent porphyria, variegate porphyria, hereditary coproporphyria, plumboporphyria)
non-acute: not enzyme inducible (cutaneous hepatic and erythropoetic porphyrias)

Front 331

porphyrin attack

Back 331

abd cramps, skin lesions, seizures

Front 332

Why does droperidol have a black box warning? uh oh!

Back 332

potential for fatal arrhythmias (QT prolongation, torsades de pointes), only give during continuous EKG monitoring and get initial ekg before admin


anti-emetic dose is so tiny that its unlikely to cause these cv problems

Front 333

What does propofol do to cortisol and aldosterone levels?

Back 333

increases!
opposite of etomidate, which decreases

Front 334

Flumenazil (Romazicon)

Back 334

- benzo antagonist
- rescue drug to reverse benzos (no other classes reversed by it)
- put it on crash carts
- give it IV

Front 335

Protein binding and half-life of flumenazil?

Back 335

protein binding- 50%
half life- short! only 40-80 min, which is less than half life of drug it is reversing -- this means you might have to give repeat doses until benzos clear from system!

Front 336

Where is flumenazil metabolized?

Back 336

liver
half life incr with liver dysfunction

Front 337

Flumenazil will clear faster if the pt

Back 337

eats!

Front 338

The dosage for flumenazil is

Back 338

0.2 mg IV over 15 sec, wait 45 sec, then give 0.2 mg IV more up to a max of 1.0 mg

Front 339

What is the patient you should never give flumenazil to?

Back 339

seizure patients

Front 340

You can't give flumenazil until you...

Back 340

reverse paralytics! or else you'll scare the shit out of them.

Front 341

This drug, even though no longer on the market, paved the way for IV anesthetics

Back 341

thiopental (1934)

Front 342

Most common IV anesthetic

Back 342

propofol

Front 343

The most frequently used benzo is is ____ because of its rapid onset and offset and lack of active metabolites

Back 343

midazolam

Front 344

The most frequently used benzo is is ____ because of its rapid onset and offset and lack of active metabolites

Back 344

midazolam

Front 345

Droperidol dose

Back 345

0.625 to 1.25 mg