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478 Cards in this Set
- Front
- Back
|
MAC Isoflurane
|
1.17
|
|
|
MAC Nitrous Oxide
|
104
|
|
|
MAC Halothane
|
0.75
|
|
|
MAC Enflurane
|
1.63
|
|
|
MAC Desflurane
|
6.6
|
|
|
MAC Sevoflurane
|
2.1
|
|
|
Vapor Pressure Isoflurane
|
240 mm Hg
|
|
|
Vapor Pressure Nitrous Oxide
|
Gas
|
|
|
Vapor Pressure Halothane
|
244 mm Hg
|
|
|
Vapor Pressure Enflurane
|
172 mm Hg
|
|
|
Vapor Pressure Desflurane
|
669 mm Hg
|
|
|
Vapor Pressure Sevoflurane
|
170 mm Hg
|
|
|
Blood:Gas partition Isoflurane
|
1.46 [4]
|
|
|
Blood:Gas partition Nitrous Oxide
|
0.46 [2]
|
|
|
Blood:Gas partition Halothane
|
2.54
|
|
|
Blood:Gas partition Enflurane
|
1.9
|
|
|
Blood:Gas partition Desflurane
|
0.42 [1]
|
|
|
Blood:Gas partition Sevoflurane
|
0.69 [3]
|
|
|
Metabolite Desflurane
|
"Carbon Monoxide
|
|
|
(may lead to Inhaled Anesthetic Hepatic Toxicity)"
|
|
|
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Metabolite Isoflurane
|
"Trifluoroacetatic acid
|
|
|
(may lead to Inhaled Anesthetic Hepatic Toxicity)"
|
|
|
|
Metabolite Sevoflurane
|
Fluoride, Compound A/trifluoromethyl vinyl-ether (dose-dependent nephrotoxin in rats, 2 MAC-hour Rule)
|
|
|
Inhaled Anesthetic Hepatic Toxicity
|
"Trifluoroacetatic acid attaches to hepatocytes -> sensitization (antitrifluoroacetylated protein antibodies).
|
|
|
Centrilobular necrosis"
|
|
|
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Side Effects Enflurane: Cardiac
|
Depresses myocardial contractility and sensitizes the myocardium to epinephrine.
|
|
|
Side Effects Enflurane: Neuro
|
"Increases secretion of CSF and resistance to CSF outflow.
|
|
|
May lead to tonic-clonic seizures during deep anesthesia."
|
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|
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Enzymes involved in hepatic metabolism
|
P-450, specifically CYP 2EI)
|
|
|
Most important route of elimination of inhaled anesthetics
|
Alveolus
|
|
|
Side Effects Nitrous Oxide: Respiratory
|
"Diffusion Hypoxia
|
|
|
Expansion of air spaces (50% will 2x, 70% will 4x)"
|
|
|
|
Meyer-Overton Rule
|
The anesthetic potency of inhalation agents correlates directly with their lipid solubility.
|
|
|
Minimum Alveolar Concentration (MAC)
|
The alveolar concentration that prevents movement in 50% of patients in response to a standardized stimulus. (Equivalent to ED50)
|
|
|
Hypoxic Drive
|
The ventilatory response to arterial hypoxia that is mediated by peripheral chemoreceptors in the carotid bodies. Markedly depressed by Nitrous.
|
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Side Effects Nitrous Oxide: Cardiac
|
"Direct myocardial depression
|
|
|
Associated with higher incidence of Epi-induced arrhythmias d/t increased catecholamine release."
|
|
|
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Side Effects Nitrous Oxide: CNS
|
"Increases CBF and volume -> mild increase in ICP.
|
|
|
Increases CMRO2."
|
|
|
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Side Effects Nitrous Oxide: Neuromuscular
|
"May cause skeletal rigidity at high concentrations (hyperbaric chamber).
|
|
|
Probably doesn’t trigger MH."
|
|
|
|
Side Effects Nitrous Oxide: Renal
|
Decreases renal blood flow by increasing renal vascular resistance -> Decreased GFR and UOP.
|
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Side Effects Nitrous Oxide: GI
|
Possibly increased post-op N/V (chemoreceptor trigger zone and vomiting center in medulla)
|
|
|
Side Effects Nitrous Oxide: Immune
|
"Inhibits B12-dependent enzymes:
|
|
|
Altered chemotaxis and mobility of WBC"
|
|
|
|
Contraindications to Nitrous Oxide
|
Air embolism, Pneumothorax, Acute intestinal obstruction, Pneumocephalus, Pulmonary air cysts, Intraocular air bubbles, tympanic membrane grafting, Pulmonary HTN, Pregnancy (poss teratogenic)
|
|
|
Critical Temperature
|
Temperature above which a liquid cannot be formed by an increase in pressure.
|
|
|
Side Effects Halothane: Cardiac
|
"Direct myocardial depression (2.0 MAC -> 50% Decrease in BP and CO)
|
|
|
Sensitizes heart to epinephrine."
|
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|
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Side Effects Halothane: Respiratory
|
"Severely depresses hypoxic drive
|
|
|
Depresses mucociliary function -> increased post-op hypoxia and atelectasis."
|
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Side Effects Halothane: CNS
|
"Blunts cerebral autoregulation
|
|
|
Decreases CMRO2"
|
|
|
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Side Effects Halothane: Neuromuscular
|
"Potentiates non-depolarizers
|
|
|
Triggers MH"
|
|
|
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Side Effects Halothane: Renal
|
Decreases renal blood flow by decreased BP and CO -> Decreased GFR and UOP.
|
|
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Side Effects Halothane: Hepatic
|
"Decreased hepatic blood flow proportional to CO.
|
|
|
Hepatic artery vasospasm."
|
|
|
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Prevents trifluoroacetic acid formation from inhalation anesthetics
|
Pretreatment with Disulfiram
|
|
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Contraindications to Halothane
|
"Unexplained liver dysfunction
|
|
|
Pheochromocytoma"
|
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Side Effects Isoflurane: Cardiac
|
"Dilates coronary arteries
|
|
|
Lowers arterial BP"
|
|
|
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Side Effects Isoflurane: Respiratory
|
"Depresses hypoxic drive
|
|
|
Good bronchodilator"
|
|
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Side Effects Isoflurane: CNS
|
">1 MAC increases CBF and ICP
|
|
|
Silent EEG at 2 MAC"
|
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Side Effects Isoflurane: Neuromuscular
|
"Potentiates non-depolarizers
|
|
|
Triggers MH"
|
|
|
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Side Effects Isoflurane: Renal
|
Decreases renal blood flow by decreased BP and CO -> Decreased GFR and UOP.
|
|
|
Side Effects Isoflurane: Hepatic
|
Hepatic blood flow is reduced
|
|
|
Malignant Hyperthermia
|
"Ryanodine receptor mutation
|
|
|
Dantrolene 2.5mg/kg, continue for 24hrs 1mg/kg q6hr"
|
|
|
|
Contraindications to Isoflurane
|
None
|
|
|
Side Effects Desflurane: Cardiac
|
Rapid increases in concentration may lead to increased HR, BP, and catecholamine levels. Attenuated by fentanyl, esmolol, or clonidine.
|
|
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Side Effects Desflurane: Respiratory
|
"Irritating to upper airways.
|
|
|
Carbon Monoxide"
|
|
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Side Effects Desflurane: CNS
|
"Increases CBF and ICP.
|
|
|
Marked decline in CMRO2."
|
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|
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Side Effects Desflurane: Neuromuscular
|
"Potentiates non-depolarizers
|
|
|
Triggers MH"
|
|
|
|
Side Effects Desflurane: Renal
|
None
|
|
|
Side Effects Desflurane: Hepatic
|
None
|
|
|
Contraindications to Desflurane
|
Severe hypovolemia, MH, intracranial hypertension
|
|
|
Signs of Carbon Monoxide poisoning under anesthesia
|
"Carboxyhemoglobin on ABG
|
|
|
Lower than expected pulse-ox"
|
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Side Effects Sevoflurane: Cardiac
|
"Lowers arterial BP
|
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CO less well maintained than with ISO"
|
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Side Effects Sevoflurane: Respiratory
|
"Non-pungent (inhalation inductions)
|
|
|
Bronchodilator"
|
|
|
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Side Effects Sevoflurane: CNS
|
>1.5 MAC may impair cerebral autoregulation
|
|
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Side Effects Sevoflurane: Neuromuscular
|
"Potentiates non-depolarizers
|
|
|
Triggers MH"
|
|
|
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Side Effects Sevoflurane: Renal
|
Compound A -> decreased concentrating ability
|
|
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Side Effects Sevoflurane: Hepatic
|
Decreases portal vein flow, but increases hepatic artery flow - net zero
|
|
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Contraindications to Sevoflurane
|
Severe hypovolemia, MH, intracranial hypertension
|
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Anatomic Dead Space
|
1 mL/kg/breath
|
|
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Equipment Dead Space
|
Compliance x Pressure
|
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Volume of Distribution
|
Dose/Concentration
|
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Thiopental: Mechanism
|
+ GABA-A
|
|
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Thiopental: CNS
|
"Constrict cerebral vasculature
|
|
|
Taste sensation of garlic or onions"
|
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Thiopental: Hepatic
|
"Induction of hepatic enzymes
|
|
|
May precipitate porphyria (induction of levulinic acid synthetase -> increases porphrin)"
|
|
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Thiopental: Immunological
|
"May cause histamine release
|
|
|
Immunosuppression"
|
|
|
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Benzodiazepine-receptor antagonist
|
Flumazenil
|
|
|
Benzodiazepines: Mechanism
|
+ GABA-A
|
|
|
Benzodiazepines: Metabolism
|
Glucuronidation
|
|
|
Diazepam: Metabolites
|
"Pharmacologically Active:
|
|
|
Oxazepam & des-methyl diazepam"
|
|
|
|
Midazolam: Metabolites
|
alpha-hydroxymidazolam
|
|
|
Midazolam: Interactions
|
Erythromycin inhibits metabolism and causes a 2-3x prolongation and intensification
|
|
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Diazepam: Interactions
|
"Cimetidine binds P-450 and reduces metabolism.
|
|
|
Opiods cause drastic drop in BP"
|
|
|
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Opioid μ-receptor
|
"Supraspinal analgesia (μ-1)
|
|
|
Muscle rigidity"
|
|
|
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Opioid κ-receptor
|
"Sedation
|
|
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Spinal alalgesia"
|
|
|
|
Opioid δ-receptor
|
"Analgesia
|
|
|
Epileptogenic"
|
|
|
|
Opioid σ-receptor
|
"Dysphoria
|
|
|
Respiratory stimulation"
|
|
|
|
Morphine: Metabolites
|
"Accumulate in renal impairment -> narcosis and ventilatory depression
|
|
|
morphine 6-glucuronide"
|
|
|
|
Meperidine: Metabolites
|
normeperidine, active metabolite associated with seizures not reversed by naloxone
|
|
|
Remifentanyl: Metabolism
|
"Unique ester structure makes it susceptible to rapid ester hydrolysis by nonspecific esterases in blood and tissue.
|
|
|
Not affected by pseudocholinesterase deficiency."
|
|
|
|
Opioids associated with histamine release
|
"Morphine and Meperidine
|
|
|
May lead to bronchospasm or profound drops in BP."
|
|
|
|
Opioids associated with muscle rigidity
|
"Fentanyl, sufentanil, and alfentanil
|
|
|
Centrally mediated muscle contraction most frequent after large boluses and treated with paralytics."
|
|
|
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Meperidine: Interactions
|
"MAO-I:
|
|
|
respiratory arrest, HTN or Hypotension, coma, hyperpyrexia"
|
|
|
|
Alfentail: Interactions
|
Erythromycin: leading to prolonged sedation and respiratory distress
|
|
|
Ketamine: Mechanism
|
"Functionally “dissociates” the Thalamus from the Limbic cortex.
|
|
|
NMDA antagonist"
|
|
|
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Ketamine: Cardiac
|
"Increases HR, BP, and CO due to central sympathetic stimulation and inhibition of norepinephrine reuptake.
|
|
|
DIRECT MYOCARDIAL DEPRESSANT"
|
|
|
|
Ketamine: Respiratory
|
Potent bronchodilator (great for asthma)
|
|
|
Ketamine: CNS
|
Increases CMRO2, blood flow, and ICP
|
|
|
Ketamine: Interactions
|
"Theophylline may predispose to seizures
|
|
|
Propranolol, phenoxybenzamine, and other sympathetic antagonists unmask cardiac depression."
|
|
|
|
Etomidate: Mechanism
|
+ GABA-A
|
|
|
Etomidate: Metabolism
|
Rapid metabolism by P-450 and plasma esterases.
|
|
|
Etomidate: CNS
|
"Decreases CMRO2, blood flow, and ICP
|
|
|
Myoclonus"
|
|
|
|
Etomidate: Endocrine
|
Induction doses transiently inhibit enzymes involved in cortisol and aldosterone synthesis. Long-term infusions lead to adrenocortical suppression.
|
|
|
Etomidate: Interactions
|
Fentanyl prolongs half-life and increases plasma level.
|
|
|
Propofol: Mechanism
|
+ GABA-A
|
|
|
Propofol: Emulsion
|
Soybean Oil, Glycerol, and Egg Lecithin (yolk)
|
|
|
Propofol Infusion Syndrome
|
"Lipemia, Metabolic (Lactic) acidosis, and death.
|
|
|
Children who are critically ill or young adult neurosurgical patients."
|
|
|
|
Propofol: Respiratory
|
"Profound respiratory depressant
|
|
|
May cause histamine release"
|
|
|
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Propofol: CNS
|
"Decreases ICP and blood flow
|
|
|
Decreases intraocular pressure"
|
|
|
|
Sensory innervation of anterior two-thirds of tongue
|
Lingual nerve (V3, Trigeminal n.)
|
|
|
Sensory innervation of posterior third of tongue
|
Glossopharyngeal nerve (IX)
|
|
|
(Nasopharynx and Oropharynx)"
|
Glossopharyngeal nerve (IX)
|
|
|
(Hypopharynx)"
|
(Internal) Superior laryngeal branch of Vagus (X)
|
|
|
Sensory innervation to larynx below the vocal cords and trachea
|
Recurrent laryngeal branch of Vagus (X)
|
|
|
How to determine ETT size in children
|
4 + Age/4
|
|
|
Nerve responsible for laryngospasm
|
Superior laryngeal nerve (X)
|
|
|
Nerve blocks for awake intubation
|
"Lingual and Glossopharyngeal (@ anterior tonsillar pillars)
|
|
|
Transtracheal"
|
|
|
|
1 cm H2O in mm Hg
|
0.74
|
|
|
Eaton-Lambert myasthenic syndrome
|
Decreased release of ACh
|
|
|
Myasthenia gravis
|
"Decreased number of ACh receptors.
|
|
|
Resistant to depolarizing relaxants and increased sensitivity to nondepolarizers."
|
|
|
|
Dibucaine Challenge
|
"Detects pseudocholinesterase mutations.
|
|
|
20% inhibition (Homozygous atypical)"
|
|
|
|
Succinylcholine: Interactions
|
"Cholinesterase inhibitors (incr [ACh], inhibit pseudocholinesterase)
|
|
|
Pancuronium (inhibits pseudocholinesterase)"
|
|
|
|
Pancuronium: Side Effects
|
"Tachycardia (Blocks muscarinic receptors in SA node)
|
|
|
Allergic rxn if hypersensitivity to bromides (pancuronium bromide)"
|
|
|
|
Atracurium: Side Effects
|
"Histamine release (also with Mivacurium)
|
|
|
(Bronchospasm, Flushing, Hypotension)"
|
|
|
|
Nondepolarizers with significant hepatic metabolism
|
VECURONIUM and pancuronium
|
|
|
Nondepolarizers that depend on biliary excretion
|
Vecuronium and Rocuronium
|
|
|
Nondepolarizers with actions prolonged in renal failure
|
Pancuronium and Vecuronium
|
|
|
Effect of magnesium on nondepolarizers
|
Hypermagnesemia, as seen in preeclamptic patients, potentiates a nondepolarizing blockade by competing with calcium at the motor end plate.
|
|
|
Atracurium: Metabolites
|
Laudanosine - CNS stimulant, may cause seizures
|
|
|
Atracurium: Metabolism
|
Hoffmann Elimination and Ester hydrolysis (nonspecific esterases)
|
|
|
Atracurium: Interactions
|
"May precipitate if given with alkaline solution (Thiopental).
|
|
|
Markedly prolonged by Hypothermia."
|
|
|
|
Cisatracurium: Metabolism
|
Entirely Hoffmann Elimination
|
|
|
Cisatracurium: Metabolites
|
Laudanosine - CNS stimulant, may cause seizures
|
|
|
Pancuronium: Metabolites
|
d-acetylpancuronium
|
|
|
Pancuronium: Metabolism
|
Mainly renal excretion (40%%) with some hepatic metabolism.
|
|
|
Pancuronium: Interactions
|
TCAs and Halothane may cause arrhythmias.
|
|
|
Vecuronium: Metabolism
|
Primarily biliary excretion, but 25% renal.
|
|
|
Vecuronium: Metabolite
|
d-acetylvecuronium (active)
|
|
|
Vecuronium: Interaction
|
May precipitate if given with alkaline solution (Thiopental).
|
|
|
Rocuronium: Side Effects
|
Most anaphylactic.
|
|
|
Rocuronium: Metabolism
|
No Metabolism. Eliminated primarily by the liver and slightly by the kidneys.
|
|
|
MAC Isoflurane
|
1.17
|
|
|
MAC Nitrous Oxide
|
104
|
|
|
MAC Halothane
|
0.75
|
|
|
MAC Enflurane
|
1.63
|
|
|
MAC Desflurane
|
6.6
|
|
|
MAC Sevoflurane
|
2.1
|
|
|
Vapor Pressure Isoflurane
|
240 mm Hg
|
|
|
Vapor Pressure Nitrous Oxide
|
Gas
|
|
|
Vapor Pressure Halothane
|
244 mm Hg
|
|
|
Vapor Pressure Enflurane
|
172 mm Hg
|
|
|
Vapor Pressure Desflurane
|
669 mm Hg
|
|
|
Vapor Pressure Sevoflurane
|
170 mm Hg
|
|
|
Blood:Gas partition Isoflurane
|
1.46 [4]
|
|
|
Blood:Gas partition Nitrous Oxide
|
0.46 [2]
|
|
|
Blood:Gas partition Halothane
|
2.54
|
|
|
Blood:Gas partition Enflurane
|
1.9
|
|
|
Blood:Gas partition Desflurane
|
0.42 [1]
|
|
|
Blood:Gas partition Sevoflurane
|
0.69 [3]
|
|
|
Metabolite Desflurane
|
"Carbon Monoxide
|
|
|
Metabolite Isoflurane
|
"Trifluoroacetatic acid
|
|
|
Metabolite Sevoflurane
|
Fluoride, Compound A/trifluoromethyl vinyl-ether (dose-dependent nephrotoxin in rats, 2 MAC-hour Rule)
|
|
|
Inhaled Anesthetic Hepatic Toxicity
|
"Trifluoroacetatic acid attaches to hepatocytes -> sensitization (antitrifluoroacetylated protein antibodies).
|
|
|
Side Effects Enflurane: Cardiac
|
Depresses myocardial contractility and sensitizes the myocardium to epinephrine.
|
|
|
Side Effects Enflurane: Neuro
|
"Increases secretion of CSF and resistance to CSF outflow.
|
|
|
Enzymes involved in hepatic metabolism
|
P-450, specifically CYP 2EI)
|
|
|
Most important route of elimination of inhaled anesthetics
|
Alveolus
|
|
|
Side Effects Nitrous Oxide: Respiratory
|
"Diffusion Hypoxia
|
|
|
Meyer-Overton Rule
|
The anesthetic potency of inhalation agents correlates directly with their lipid solubility.
|
|
|
Minimum Alveolar Concentration (MAC)
|
The alveolar concentration that prevents movement in 50% of patients in response to a standardized stimulus. (Equivalent to ED50)
|
|
|
Hypoxic Drive
|
The ventilatory response to arterial hypoxia that is mediated by peripheral chemoreceptors in the carotid bodies. Markedly depressed by Nitrous.
|
|
|
Side Effects Nitrous Oxide: Cardiac
|
"Direct myocardial depression
|
|
|
Side Effects Nitrous Oxide: CNS
|
"Increases CBF and volume -> mild increase in ICP.
|
|
|
Side Effects Nitrous Oxide: Neuromuscular
|
"May cause skeletal rigidity at high concentrations (hyperbaric chamber).
|
|
|
Side Effects Nitrous Oxide: Renal
|
Decreases renal blood flow by increasing renal vascular resistance -> Decreased GFR and UOP.
|
|
|
Side Effects Nitrous Oxide: GI
|
Possibly increased post-op N/V (chemoreceptor trigger zone and vomiting center in medulla)
|
|
|
Side Effects Nitrous Oxide: Immune
|
"Inhibits B12-dependent enzymes:
|
|
|
Contraindications to Nitrous Oxide
|
Air embolism, Pneumothorax, Acute intestinal obstruction, Pneumocephalus, Pulmonary air cysts, Intraocular air bubbles, tympanic membrane grafting, Pulmonary HTN, Pregnancy (poss teratogenic)
|
|
|
Critical Temperature
|
Temperature above which a liquid cannot be formed by an increase in pressure.
|
|
|
Side Effects Halothane: Cardiac
|
"Direct myocardial depression (2.0 MAC -> 50% Decrease in BP and CO)
|
|
|
Side Effects Halothane: Respiratory
|
"Severely depresses hypoxic drive
|
|
|
Side Effects Halothane: CNS
|
"Blunts cerebral autoregulation
|
|
|
Side Effects Halothane: Neuromuscular
|
"Potentiates non-depolarizers
|
|
|
Side Effects Halothane: Renal
|
Decreases renal blood flow by decreased BP and CO -> Decreased GFR and UOP.
|
|
|
Side Effects Halothane: Hepatic
|
"Decreased hepatic blood flow proportional to CO.
|
|
|
Prevents trifluoroacetic acid formation from inhalation anesthetics
|
Pretreatment with Disulfiram
|
|
|
Contraindications to Halothane
|
"Unexplained liver dysfunction
|
|
|
Side Effects Isoflurane: Cardiac
|
"Dilates coronary arteries
|
|
|
Side Effects Isoflurane: Respiratory
|
"Depresses hypoxic drive
|
|
|
Side Effects Isoflurane: CNS
|
">1 MAC increases CBF and ICP
|
|
|
Side Effects Isoflurane: Neuromuscular
|
"Potentiates non-depolarizers
|
|
|
Side Effects Isoflurane: Renal
|
Decreases renal blood flow by decreased BP and CO -> Decreased GFR and UOP.
|
|
|
Side Effects Isoflurane: Hepatic
|
Hepatic blood flow is reduced
|
|
|
Malignant Hyperthermia
|
"Ryanodine receptor mutation
|
|
|
Contraindications to Isoflurane
|
None
|
|
|
Side Effects Desflurane: Cardiac
|
Rapid increases in concentration may lead to increased HR, BP, and catecholamine levels. Attenuated by fentanyl, esmolol, or clonidine.
|
|
|
Side Effects Desflurane: Respiratory
|
"Irritating to upper airways.
|
|
|
Side Effects Desflurane: CNS
|
"Increases CBF and ICP.
|
|
|
Side Effects Desflurane: Neuromuscular
|
"Potentiates non-depolarizers
|
|
|
Side Effects Desflurane: Renal
|
None
|
|
|
Side Effects Desflurane: Hepatic
|
None
|
|
|
Contraindications to Desflurane
|
Severe hypovolemia, MH, intracranial hypertension
|
|
|
Signs of Carbon Monoxide poisoning under anesthesia
|
"Carboxyhemoglobin on ABG
|
|
|
Side Effects Sevoflurane: Cardiac
|
"Lowers arterial BP
|
|
|
Side Effects Sevoflurane: Respiratory
|
"Non-pungent (inhalation inductions)
|
|
|
Side Effects Sevoflurane: CNS
|
>1.5 MAC may impair cerebral autoregulation
|
|
|
Side Effects Sevoflurane: Neuromuscular
|
"Potentiates non-depolarizers
|
|
|
Side Effects Sevoflurane: Renal
|
Compound A -> decreased concentrating ability
|
|
|
Side Effects Sevoflurane: Hepatic
|
Decreases portal vein flow, but increases hepatic artery flow - net zero
|
|
|
Contraindications to Sevoflurane
|
Severe hypovolemia, MH, intracranial hypertension
|
|
|
Anatomic Dead Space
|
1 mL/kg/breath
|
|
|
Equipment Dead Space
|
Compliance x Pressure
|
|
|
Volume of Distribution
|
Dose/Concentration
|
|
|
Thiopental: Mechanism
|
+ GABA-A
|
|
|
Thiopental: CNS
|
"Constrict cerebral vasculature
|
|
|
Thiopental: Hepatic
|
"Induction of hepatic enzymes
|
|
|
Thiopental: Immunological
|
"May cause histamine release
|
|
|
Benzodiazepine-receptor antagonist
|
Flumazenil
|
|
|
Benzodiazepines: Mechanism
|
+ GABA-A
|
|
|
Benzodiazepines: Metabolism
|
Glucuronidation
|
|
|
Diazepam: Metabolites
|
"Pharmacologically Active:
|
|
|
Midazolam: Metabolites
|
alpha-hydroxymidazolam
|
|
|
Midazolam: Interactions
|
Erythromycin inhibits metabolism and causes a 2-3x prolongation and intensification
|
|
|
Diazepam: Interactions
|
"Cimetidine binds P-450 and reduces metabolism.
|
|
|
Opioid μ-receptor
|
"Supraspinal analgesia (μ-1)
|
|
|
Opioid κ-receptor
|
"Sedation
|
|
|
Opioid δ-receptor
|
"Analgesia
|
|
|
Opioid σ-receptor
|
"Dysphoria
|
|
|
Morphine: Metabolites
|
"Accumulate in renal impairment -> narcosis and ventilatory depression
|
|
|
Meperidine: Metabolites
|
normeperidine, active metabolite associated with seizures not reversed by naloxone
|
|
|
Remifentanyl: Metabolism
|
"Unique ester structure makes it susceptible to rapid ester hydrolysis by nonspecific esterases in blood and tissue.
|
|
|
Opioids associated with histamine release
|
"Morphine and Meperidine
|
|
|
Opioids associated with muscle rigidity
|
"Fentanyl, sufentanil, and alfentanil
|
|
|
Meperidine: Interactions
|
"MAO-I:
|
|
|
Alfentail: Interactions
|
Erythromycin: leading to prolonged sedation and respiratory distress
|
|
|
Ketamine: Mechanism
|
"Functionally “dissociates” the Thalamus from the Limbic cortex.
|
|
|
Ketamine: Cardiac
|
"Increases HR, BP, and CO due to central sympathetic stimulation and inhibition of norepinephrine reuptake.
|
|
|
Ketamine: Respiratory
|
Potent bronchodilator (great for asthma)
|
|
|
Ketamine: CNS
|
Increases CMRO2, blood flow, and ICP
|
|
|
Ketamine: Interactions
|
"Theophylline may predispose to seizures
|
|
|
Etomidate: Mechanism
|
+ GABA-A
|
|
|
Etomidate: Metabolism
|
Rapid metabolism by P-450 and plasma esterases.
|
|
|
Etomidate: CNS
|
"Decreases CMRO2, blood flow, and ICP
|
|
|
Etomidate: Endocrine
|
Induction doses transiently inhibit enzymes involved in cortisol and aldosterone synthesis. Long-term infusions lead to adrenocortical suppression.
|
|
|
Etomidate: Interactions
|
Fentanyl prolongs half-life and increases plasma level.
|
|
|
Propofol: Mechanism
|
+ GABA-A
|
|
|
Propofol: Emulsion
|
Soybean Oil, Glycerol, and Egg Lecithin (yolk)
|
|
|
Propofol Infusion Syndrome
|
"Lipemia, Metabolic (Lactic) acidosis, and death.
|
|
|
Propofol: Respiratory
|
"Profound respiratory depressant
|
|
|
Propofol: CNS
|
"Decreases ICP and blood flow
|
|
|
Sensory innervation of anterior two-thirds of tongue
|
Lingual nerve (V3, Trigeminal n.)
|
|
|
Sensory innervation of posterior third of tongue
|
Glossopharyngeal nerve (IX)
|
|
|
(Nasopharynx and Oropharynx)"
|
Glossopharyngeal nerve (IX)
|
|
|
(Hypopharynx)"
|
(Internal) Superior laryngeal branch of Vagus (X)
|
|
|
Sensory innervation to larynx below the vocal cords and trachea
|
Recurrent laryngeal branch of Vagus (X)
|
|
|
How to determine ETT size in children
|
4 + Age/4
|
|
|
Nerve responsible for laryngospasm
|
Superior laryngeal nerve (X)
|
|
|
Nerve blocks for awake intubation
|
"Lingual and Glossopharyngeal (@ anterior tonsillar pillars)
|
|
|
1 cm H2O in mm Hg
|
0.74
|
|
|
Eaton-Lambert myasthenic syndrome
|
Decreased release of ACh
|
|
|
Myasthenia gravis
|
"Decreased number of ACh receptors.
|
|
|
Dibucaine Challenge
|
"Detects pseudocholinesterase mutations.
|
|
|
Succinylcholine: Interactions
|
"Cholinesterase inhibitors (incr [ACh], inhibit pseudocholinesterase)
|
|
|
Pancuronium: Side Effects
|
"Tachycardia (Blocks muscarinic receptors in SA node)
|
|
|
Atracurium: Side Effects
|
"Histamine release (also with Mivacurium)
|
|
|
Nondepolarizers with significant hepatic metabolism
|
VECURONIUM and pancuronium
|
|
|
Nondepolarizers that depend on biliary excretion
|
Vecuronium and Rocuronium
|
|
|
Nondepolarizers with actions prolonged in renal failure
|
Pancuronium and Vecuronium
|
|
|
Effect of magnesium on nondepolarizers
|
Hypermagnesemia, as seen in preeclamptic patients, potentiates a nondepolarizing blockade by competing with calcium at the motor end plate.
|
|
|
Atracurium: Metabolites
|
Laudanosine - CNS stimulant, may cause seizures
|
|
|
Atracurium: Metabolism
|
Hoffmann Elimination and Ester hydrolysis (nonspecific esterases)
|
|
|
Atracurium: Interactions
|
"May precipitate if given with alkaline solution (Thiopental).
|
|
|
Cisatracurium: Metabolism
|
Entirely Hoffmann Elimination
|
|
|
Cisatracurium: Metabolites
|
Laudanosine - CNS stimulant, may cause seizures
|
|
|
Pancuronium: Metabolites
|
d-acetylpancuronium
|
|
|
Pancuronium: Metabolism
|
Mainly renal excretion (40%%) with some hepatic metabolism.
|
|
|
Pancuronium: Interactions
|
TCAs and Halothane may cause arrhythmias.
|
|
|
Vecuronium: Metabolism
|
Primarily biliary excretion, but 25% renal.
|
|
|
Vecuronium: Metabolite
|
d-acetylvecuronium (active)
|
|
|
Vecuronium: Interaction
|
May precipitate if given with alkaline solution (Thiopental).
|
|
|
Rocuronium: Side Effects
|
Most anaphylactic.
|
|
|
Rocuronium: Metabolism
|
No Metabolism. Eliminated primarily by the liver and slightly by the kidneys.
|
|
|
MAC Isoflurane
|
1.17
|
|
|
MAC Nitrous Oxide
|
104
|
|
|
MAC Halothane
|
0.75
|
|
|
MAC Enflurane
|
1.63
|
|
|
MAC Desflurane
|
6.6
|
|
|
MAC Sevoflurane
|
2.1
|
|
|
Vapor Pressure Isoflurane
|
240 mm Hg
|
|
|
Vapor Pressure Nitrous Oxide
|
Gas
|
|
|
Vapor Pressure Halothane
|
244 mm Hg
|
|
|
Vapor Pressure Enflurane
|
172 mm Hg
|
|
|
Vapor Pressure Desflurane
|
669 mm Hg
|
|
|
Vapor Pressure Sevoflurane
|
170 mm Hg
|
|
|
Blood:Gas partition Isoflurane
|
1.46 [4]
|
|
|
Blood:Gas partition Nitrous Oxide
|
0.46 [2]
|
|
|
Blood:Gas partition Halothane
|
2.54
|
|
|
Blood:Gas partition Enflurane
|
1.9
|
|
|
Blood:Gas partition Desflurane
|
0.42 [1]
|
|
|
Blood:Gas partition Sevoflurane
|
0.69 [3]
|
|
|
Metabolite Desflurane
|
"Carbon Monoxide
Trifluoroacetatic acid (may lead to Inhaled Anesthetic Hepatic Toxicity)" |
|
|
Metabolite Isoflurane
|
"Trifluoroacetatic acid
(may lead to Inhaled Anesthetic Hepatic Toxicity)" |
|
|
Metabolite Sevoflurane
|
Fluoride, Compound A/trifluoromethyl vinyl-ether (dose-dependent nephrotoxin in rats, 2 MAC-hour Rule)
|
|
|
Inhaled Anesthetic Hepatic Toxicity
|
"Trifluoroacetatic acid attaches to hepatocytes -> sensitization (antitrifluoroacetylated protein antibodies).
Subsequent exposures -> immune-modulated reaction. 1. ISO 2. DES 3. HALOTHANE SEVO does not cause! 1/35,000 "Centrilobular necrosis" |
|
|
Side Effects Enflurane: Cardiac
|
Depresses myocardial contractility and sensitizes the myocardium to epinephrine.
|
|
|
Side Effects Enflurane: Neuro
|
"Increases secretion of CSF and resistance to CSF outflow.
May lead to tonic-clonic seizures during deep anesthesia." |
|
|
Enzymes involved in hepatic metabolism
|
P-450, specifically CYP 2EI)
|
|
|
Most important route of elimination of inhaled anesthetics
|
Alveolus
|
|
|
Side Effects Nitrous Oxide: Respiratory
|
"Diffusion Hypoxia
Depresses Hypoxic Drive Expansion of air spaces (50% will 2x, 70% will 4x)" |
|
|
Meyer-Overton Rule
|
The anesthetic potency of inhalation agents correlates directly with their lipid solubility.
|
|
|
Minimum Alveolar Concentration (MAC)
|
The alveolar concentration that prevents movement in 50% of patients in response to a standardized stimulus. (Equivalent to ED50)
|
|
|
Hypoxic Drive
|
The ventilatory response to arterial hypoxia that is mediated by peripheral chemoreceptors in the carotid bodies. Markedly depressed by Nitrous.
|
|
|
Side Effects Nitrous Oxide: Cardiac
|
"Direct myocardial depression
|
|
|
Side Effects Nitrous Oxide: CNS
|
"Increases CBF and volume -> mild increase in ICP.
|
|
|
Side Effects Nitrous Oxide: Neuromuscular
|
"May cause skeletal rigidity at high concentrations (hyperbaric chamber).
|
|
|
Side Effects Nitrous Oxide: Renal
|
Decreases renal blood flow by increasing renal vascular resistance -> Decreased GFR and UOP.
|
|
|
Side Effects Nitrous Oxide: GI
|
Possibly increased post-op N/V (chemoreceptor trigger zone and vomiting center in medulla)
|
|
|
Side Effects Nitrous Oxide: Immune
|
"Inhibits B12-dependent enzymes:
|
|
|
Contraindications to Nitrous Oxide
|
Air embolism, Pneumothorax, Acute intestinal obstruction, Pneumocephalus, Pulmonary air cysts, Intraocular air bubbles, tympanic membrane grafting, Pulmonary HTN, Pregnancy (poss teratogenic)
|
|
|
Critical Temperature
|
Temperature above which a liquid cannot be formed by an increase in pressure.
|
|
|
Side Effects Halothane: Cardiac
|
"Direct myocardial depression (2.0 MAC -> 50% Decrease in BP and CO)
|
|
|
Side Effects Halothane: Respiratory
|
"Severely depresses hypoxic drive
|
|
|
Side Effects Halothane: CNS
|
"Blunts cerebral autoregulation
|
|
|
Side Effects Halothane: Neuromuscular
|
"Potentiates non-depolarizers
|
|
|
Side Effects Halothane: Renal
|
Decreases renal blood flow by decreased BP and CO -> Decreased GFR and UOP.
|
|
|
Side Effects Halothane: Hepatic
|
"Decreased hepatic blood flow proportional to CO.
|
|
|
Prevents trifluoroacetic acid formation from inhalation anesthetics
|
Pretreatment with Disulfiram
|
|
|
Contraindications to Halothane
|
"Unexplained liver dysfunction
|
|
|
Side Effects Isoflurane: Cardiac
|
"Dilates coronary arteries
|
|
|
Side Effects Isoflurane: Respiratory
|
"Depresses hypoxic drive
|
|
|
Side Effects Isoflurane: CNS
|
">1 MAC increases CBF and ICP
|
|
|
Side Effects Isoflurane: Neuromuscular
|
"Potentiates non-depolarizers
|
|
|
Side Effects Isoflurane: Renal
|
Decreases renal blood flow by decreased BP and CO -> Decreased GFR and UOP.
|
|
|
Side Effects Isoflurane: Hepatic
|
Hepatic blood flow is reduced
|
|
|
Malignant Hyperthermia
|
"Ryanodine receptor mutation
|
|
|
Contraindications to Isoflurane
|
None
|
|
|
Side Effects Desflurane: Cardiac
|
Rapid increases in concentration may lead to increased HR, BP, and catecholamine levels. Attenuated by fentanyl, esmolol, or clonidine.
|
|
|
Side Effects Desflurane: Respiratory
|
"Irritating to upper airways.
|
|
|
Side Effects Desflurane: CNS
|
"Increases CBF and ICP.
|
|
|
Side Effects Desflurane: Neuromuscular
|
"Potentiates non-depolarizers
|
|
|
Side Effects Desflurane: Renal
|
None
|
|
|
Side Effects Desflurane: Hepatic
|
None
|
|
|
Contraindications to Desflurane
|
Severe hypovolemia, MH, intracranial hypertension
|
|
|
Signs of Carbon Monoxide poisoning under anesthesia
|
"Carboxyhemoglobin on ABG
|
|
|
Side Effects Sevoflurane: Cardiac
|
"Lowers arterial BP
|
|
|
Side Effects Sevoflurane: Respiratory
|
"Non-pungent (inhalation inductions)
|
|
|
Side Effects Sevoflurane: CNS
|
>1.5 MAC may impair cerebral autoregulation
|
|
|
Side Effects Sevoflurane: Neuromuscular
|
"Potentiates non-depolarizers
|
|
|
Side Effects Sevoflurane: Renal
|
Compound A -> decreased concentrating ability
|
|
|
Side Effects Sevoflurane: Hepatic
|
Decreases portal vein flow, but increases hepatic artery flow - net zero
|
|
|
Contraindications to Sevoflurane
|
Severe hypovolemia, MH, intracranial hypertension
|
|
|
Anatomic Dead Space
|
1 mL/kg/breath
|
|
|
Equipment Dead Space
|
Compliance x Pressure
|
|
|
Volume of Distribution
|
Dose/Concentration
|
|
|
Thiopental: Mechanism
|
+ GABA-A
|
|
|
Thiopental: CNS
|
"Constrict cerebral vasculature
|
|
|
Thiopental: Hepatic
|
"Induction of hepatic enzymes
|
|
|
Thiopental: Immunological
|
"May cause histamine release
|
|
|
Benzodiazepine-receptor antagonist
|
Flumazenil
|
|
|
Benzodiazepines: Mechanism
|
+ GABA-A
|
|
|
Benzodiazepines: Metabolism
|
Glucuronidation
|
|
|
Diazepam: Metabolites
|
"Pharmacologically Active:
|
|
|
Midazolam: Metabolites
|
alpha-hydroxymidazolam
|
|
|
Midazolam: Interactions
|
Erythromycin inhibits metabolism and causes a 2-3x prolongation and intensification
|
|
|
Diazepam: Interactions
|
"Cimetidine binds P-450 and reduces metabolism.
|
|
|
Opioid μ-receptor
|
"Supraspinal analgesia (μ-1)
|
|
|
Opioid κ-receptor
|
"Sedation
|
|
|
Opioid δ-receptor
|
"Analgesia
|
|
|
Opioid σ-receptor
|
"Dysphoria
|
|
|
Morphine: Metabolites
|
"Accumulate in renal impairment -> narcosis and ventilatory depression
|
|
|
Meperidine: Metabolites
|
normeperidine, active metabolite associated with seizures not reversed by naloxone
|
|
|
Remifentanyl: Metabolism
|
"Unique ester structure makes it susceptible to rapid ester hydrolysis by nonspecific esterases in blood and tissue.
|
|
|
Opioids associated with histamine release
|
"Morphine and Meperidine
|
|
|
Opioids associated with muscle rigidity
|
"Fentanyl, sufentanil, and alfentanil
|
|
|
Meperidine: Interactions
|
"MAO-I:
|
|
|
Alfentail: Interactions
|
Erythromycin: leading to prolonged sedation and respiratory distress
|
|
|
Ketamine: Mechanism
|
"Functionally “dissociates” the Thalamus from the Limbic cortex.
|
|
|
Ketamine: Cardiac
|
"Increases HR, BP, and CO due to central sympathetic stimulation and inhibition of norepinephrine reuptake.
|
|
|
Ketamine: Respiratory
|
Potent bronchodilator (great for asthma)
|
|
|
Ketamine: CNS
|
Increases CMRO2, blood flow, and ICP
|
|
|
Ketamine: Interactions
|
"Theophylline may predispose to seizures
|
|
|
Etomidate: Mechanism
|
+ GABA-A
|
|
|
Etomidate: Metabolism
|
Rapid metabolism by P-450 and plasma esterases.
|
|
|
Etomidate: CNS
|
"Decreases CMRO2, blood flow, and ICP
|
|
|
Etomidate: Endocrine
|
Induction doses transiently inhibit enzymes involved in cortisol and aldosterone synthesis. Long-term infusions lead to adrenocortical suppression.
|
|
|
Etomidate: Interactions
|
Fentanyl prolongs half-life and increases plasma level.
|
|
|
Propofol: Mechanism
|
+ GABA-A
|
|
|
Propofol: Emulsion
|
Soybean Oil, Glycerol, and Egg Lecithin (yolk)
|
|
|
Propofol Infusion Syndrome
|
"Lipemia, Metabolic (Lactic) acidosis, and death.
|
|
|
Propofol: Respiratory
|
"Profound respiratory depressant
|
|
|
Propofol: CNS
|
"Decreases ICP and blood flow
|
|
|
Sensory innervation of anterior two-thirds of tongue
|
Lingual nerve (V3, Trigeminal n.)
|
|
|
Sensory innervation of posterior third of tongue
|
Glossopharyngeal nerve (IX)
|
|
|
(Nasopharynx and Oropharynx)"
|
Glossopharyngeal nerve (IX)
|
|
|
(Hypopharynx)"
|
(Internal) Superior laryngeal branch of Vagus (X)
|
|
|
Sensory innervation to larynx below the vocal cords and trachea
|
Recurrent laryngeal branch of Vagus (X)
|
|
|
How to determine ETT size in children
|
4 + Age/4
|
|
|
Nerve responsible for laryngospasm
|
Superior laryngeal nerve (X)
|
|
|
Nerve blocks for awake intubation
|
"Lingual and Glossopharyngeal (@ anterior tonsillar pillars)
|
|
|
1 cm H2O in mm Hg
|
0.74
|
|
|
Eaton-Lambert myasthenic syndrome
|
Decreased release of ACh
|
|
|
Myasthenia gravis
|
"Decreased number of ACh receptors.
|
|
|
Dibucaine Challenge
|
"Detects pseudocholinesterase mutations.
|
|
|
Succinylcholine: Interactions
|
"Cholinesterase inhibitors (incr [ACh], inhibit pseudocholinesterase)
|
|
|
Pancuronium: Side Effects
|
"Tachycardia (Blocks muscarinic receptors in SA node)
|
|
|
Atracurium: Side Effects
|
"Histamine release (also with Mivacurium)
|
|
|
Nondepolarizers with significant hepatic metabolism
|
VECURONIUM and pancuronium
|
|
|
Nondepolarizers that depend on biliary excretion
|
Vecuronium and Rocuronium
|
|
|
Nondepolarizers with actions prolonged in renal failure
|
Pancuronium and Vecuronium
|
|
|
Effect of magnesium on nondepolarizers
|
Hypermagnesemia, as seen in preeclamptic patients, potentiates a nondepolarizing blockade by competing with calcium at the motor end plate.
|
|
|
Atracurium: Metabolites
|
Laudanosine - CNS stimulant, may cause seizures
|
|
|
Atracurium: Metabolism
|
Hoffmann Elimination and Ester hydrolysis (nonspecific esterases)
|
|
|
Atracurium: Interactions
|
"May precipitate if given with alkaline solution (Thiopental).
|
|
|
Cisatracurium: Metabolism
|
Entirely Hoffmann Elimination
|
|
|
Cisatracurium: Metabolites
|
Laudanosine - CNS stimulant, may cause seizures
|
|
|
Pancuronium: Metabolites
|
d-acetylpancuronium
|
|
|
Pancuronium: Metabolism
|
Mainly renal excretion (40%%) with some hepatic metabolism.
|
|
|
Pancuronium: Interactions
|
TCAs and Halothane may cause arrhythmias.
|
|
|
Vecuronium: Metabolism
|
Primarily biliary excretion, but 25% renal.
|
|
|
Vecuronium: Metabolite
|
d-acetylvecuronium (active)
|
|
|
Vecuronium: Interaction
|
May precipitate if given with alkaline solution (Thiopental).
|
|
|
Rocuronium: Side Effects
|
Most anaphylactic.
|
|
|
Rocuronium: Metabolism
|
No Metabolism. Eliminated primarily by the liver and slightly by the kidneys.
|
