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67 Cards in this Set

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Propofol




MOA


Metabolism


Special properties

-Enhancement of GABA at receptors


-Hepatic metabolism, but quick emergence due to redistrubution


-No analgesia



Thiopental




MOA


Metabolism


Special properties


-Similar to propofol


-Hepatic metabolism, but quick emergence from redistribution


-Used for burst suppression in neurosurg





Etomidate




MOA


Metabolism


Special properties

-Similar as propofol, enhances GABA


-Hepatic metabolism, but redistribution causes quick emergence


-myoclonus and adrenal suppression


-Relative hemodynamic stability

Ketamine




MOA


Metabolism


Special Properties

NMDA antagonist


Hepatic metabolism


Analegesia and anesthesia


Side effects: hallucinations, ICP, IOP, increased salivation, bronchodilation


-INCREASE BP/HR



Short to long acting Benzos

Midaz


Diaz


Loraz

DOC for post-op shivering

Meperidine

Contraindications to Succinylcholine

H/o MH


Hyperkalemia


Burns


Denervation


Increased IOP

Nondepolarizing neuromuscular blockers

Benzylisoquinolones


Atracurium, cisatracurium




Aminosteroids


Vecuronium, rocuronium, pancuronium

Metabolism of atracurium

Spontaneously via hofman rxn


(same as cisatracurium)


-prefered in renal failure

Metabolism of rocuronium

Renal excretion


(use atra/cisatra in renal failure)

Metabolism of Succinylcholine

PLASMA cholinesterase

Physiologic changes seen with volatile anesthestics

Decreased BP via SVR, increased RR, decreased TV

Nitrous Oxide

Hemodynamic stability


Increased RR, decreased TV


May increase PONV


Commonly used as part of peds inhalation induction

Slowest to fastest volatile anesthetic agent

Isoflurane (MAC 1%) - slowest on and off


Sevo (MAC 2%)


Des (MAC 6%)

Toxic dose of lidocaine and bupivicaine

Lido: 5/7 mg/kg


Bupi: 2/3 mg/kg

Calculation of 1% lidocaine

1% = 10 mg/mL

Which induction agent increased ICP?

Ketamine


-also increased CBF

Which induction agent increased SVR?

Ketamine

Which induction agent increases BP?

Ketamine

Which induction agent increases HR?

Thiopental, ketamine and sometimes etomidate

Ephedrine

B1>a1 effects, also releases NE


Increases HR, BP, SVR

Dopamine

Dose dependent effects


-renal dose is small


-medium mostly beta, increased contractility


-high mostly alpha, increases BP/pulse

Norepinephrine

A and B effects (a>B)

Epinephrine

A and B effects, more increased contractility and heart rate, modest increase in BP


-effects metabolism resulting in hyperglycemia

Nitroglycerin

Venodilation>arteriolar dilation


-reduces myocardial oxygen consumption

Nitroprusside

More arterial dilation than nitroglycerine

Labetalol

Selective a1 and nonselective B receptor antagonist


-decreases BP and HR

Esmolol

Selective B1 antagonist


-decrease HR with some decrease in BP

Calculate allowable blood loss

Can let hgb get to 7




(original Hgb - 7)/original hgb x (70mL/kg x weight)

How to treat post-dural puncture headache

Hydration and caffeine


-or tramadol


-or blood patch (injection of blood into the back)

Signs of local anesthetic toxicity

Perioral numbness, metallic taste, tinnitus, seizure (at very high doses)

Tx of local anesthetic toxicity

Lidocaine: short acting, support for 15 minutes until it passes


Bupivicaine: much longer reaction - tx is FAT EMULSION

5 reasons to add EPI to local anesthetic

1. prolongs action of local anesthetic


2. blunts systemic uptake and limits systemic toxicity


3. decreases bleeding at injection site


4. marker of intravascular injection (increased HR)


5. Improves quality of spinal blockade via alpha receptors

Dexmetomidine

alpha2 agonist (reduces adrenergic activity)


-sedative and analgesic


-strong bradycardia, hypotension and hypothermia seen


-only given in slow infusion


-very long halflife


-no respiratory depression

Differences between peds and adult airway

Floppy epiglottis (use straight blade)


Larynx higher in neck (laryngoscopy looks relatively anterior)


Cricoid cartilage is narrowest point of airway (unlike adult in which vocal folds are smallest)

NPO deficit

Hours NPO x hourly maintenance rate


-give half in an hour, then a quarter the next hour and a quarter the next hour, in addition to maintenance!

How long do you keep infants after surgery?

Term


-44 week post-conceptual: need 24 hour stay




Preterm: need 24 hour stay up to 55 weeks PCA

Important history for a child

Medical history


Medications


Allergies


Recent URI?

NPO guidelines

clear liquids: 2 hrs


Breast milk: 4 hrs


Formula, cows milk, light meal: 6 hrs


Solids: 8 hrs

4 anatomic airway differences in kids

-Proportionally larger head (occiput and tongue)


-More anterior and cephalad larynx


-Long, floppy, omega-shaped epiglottis


-Short trachea and neck



Rapid sequence intubation steps

Preoxygenate


Apply cricoid pressure


Give fast acting anesthetic and analgesic


Intubate


Confirm w/capnography


Release cricoid pressure

When is the largest increase in CO during birth?

After delivery of the placenta

Where are pain receptors located in the spinal cord?

Dorsal horn

What are a2 receptors in the dorsal horn of spinal cord?

Inhibitory modulators

Who needs a preop EKG?

Men over 50


Women and diabetics over 40

Who needs a preop hgb?

Menstruating women

Who needs a CXR preop?

Smokers


Dobutamine

B1 agonist with some B2 and a effects


-increases CO without change in HR


-decreases preload

Isoproterenol

B1 and B2 agonist, no a activity


-Increases HR and contractility


-decreases SVR

Amrinone/Milrinione

Phosphodiesterase (PDE) inhibitors


-increase cAMP in cardiac and vascular smooth muscle, leading to increased intracellular calcium and increased contractility, decreased SVR and increased CO


-action independent of B-adrenergic receptors


-Milrinone shorter halflife, amrinone onset faster

Ester anesthestics

Only 1 "i"


Procaine


Tetracaine


2-chloroprocaine




Metabolised to PABA, that can cause allergy

Metabolism of ester anesthetics

Plamsa pseudocholinesterase

Amides

(Have 2 "i"s in names)


Mostly what we use today


Lidocaine


Bupivicaine


Mepivicaine


Prilocaine


Ropivacaine

Result of intravascular injection of bupivacaine

Cardiac asystole

3 CV physiologic changes of pregnancy

Increased intravascular fluid volume


Increased CO


Decreased SVR

Pulmonary changes in pregnancy

Upper airway has vascular edema, bleed more easily


Relative hyperventilation, minute ventilation increases


RV and FRC decrease (reserve is diminished, anesthetized more easily with volatile agents)

GI changes in pregnancy

Decreased gastric emptying and motility


Increased gastric reflux, more prone to aspiration

HOw much blood do you transfuse into a child?

10 mL/kg will raise hgb about 2 points

CV differences in peds patients

Higher CO


HR dependent (fixed stroke volume)


Respond to stress by becoming bradycardic


Higher HR and lower BP

Pulm differences in peds patients

Increased minute ventilation and RR


Desat rapidly due to increased oxygen consumption/kg


Decreased FRC under anesthesia due to small alveoli and compliant chest wall

Replacement of blood loss in children

3 mL of crystalloid for each mL blood lost

Tx laryngospasm

CPAP


-if not successful, propofol to deepen anesthesia


-ultimately succinylcholine for refractory laryngospasm

Management of can't intubate, can ventilate

Wake up


Fiberoptic scope


Eschmann stylet


Other airway (LMA)

Management of can't intubate, can't ventilate

Call for help, figure something out


-LMA, combitube


-surgical airway if needed

Why do you use rapid sequence intubation?

TO decrease risk of aspiration


-it avoids bag masking

Moderate sedation

Drug-induced level of consciousness during which patients respond appropriately to verbal commands


-maintain ventilatory and CV function

Deep sedaton

Patient responsive only to more profound stimulus


-(reflex withdrawl from pain is NOT considered purposeful, and would be considered general anesthesia)