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Anesthesia
OMFS anesthesia
104
Medical
Professional
01/07/2007

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Term
Versed
Definition
Midazolam -- benzodiazepine sedative, anxiolytic, amnesia, anesthetic adjunct Reversal--> flumazenil (Romazicon) 0.2mg every 1-2 minutes til desired effect (max 3mg over 1hr)
contraindicated in pts with seizure hx
Term
Succinylcholine
Definition
Depolarizing neuromuscular relaxant
vial: 20mg/ml
Dose: 1mg/kg
Term
Propofol
Definition
Anesthetic
10mg/ml
Induction: 2.0-2.5 mg/kg 70kg: 140-175mg; 80kg: 80-200mg Sedation: 100-150mcg/kg then 25-75 mcg/kg (70kg: 70-105mg, then 1.8-5.3 mg/min)
Term
Fentanyl
Definition
(Sublimaze)
opiod used for analgesia, anesthesia
50mcg/mL
Can cause respiratory depression, muscle rigidity, N/V, urinary retension, sedation
Term
Infant/Children tube size
Definition
[(Age +4)/2] tube size
multiply by 3 --> insertion depth
Term
Succinyl Choline
dose for infant/child
Definition
infant: 2.0 mg/kg
child: 1.0 mg/kg
Term
How Does Scavenger Work?
Definition
One Way Exhaling Valve Attached To Vacuum
Mask Within A Mask Outer Attached to Vacuum
95-97% Gas Removed By Scavenging
Term
Can you use anesthetic gases with Nasal hood?
Definition
Yes
Term
Size of Peds ET tube?
Definition
(Age of Patient + 16)/4
Term
Depth of insertion of Peds ET tube?
Definition
Age in yrs/2 + 12
Term
LMA size.

How Much air into cuff
Definition
small adult 50-70kg size 4


add a 0 to size, subtract 10cc
Term
Contraindications to placement of Combitube
Definition
Pt < 4ft tall
intact gag reflex
known esophageal disease
Laryngeal Foreign Bodies or Pathology
Term
How deep do you insert Combitube?
Definition
incisors to between black lines
Term
With Combitube which color do you blow up and ventilate through first?
Definition
1. white, connnect circuit and check for breath sounds (in trachea)
2. inflate blue balloon and ventilate
Term
Combitube: what if you can't ventilate?
Definition
Pull it back 2-3cm
it's likely resting against the esophagus
Term
Benzodiazapine mechanism of action
Definition
enhance Cl- channel passageat GABA gate
hyperpolarizes cell
GABA receptors found (nearly) only in CNS
Term
Does Versed metabolize to active metabolites?
Diazapam?
Definition
VERSED only one inactive metabolite

Diazepam: metabolized to active metabolites, oxazepam and esmethyldiazepam – prolonged CNS effects
Term
VERSED Quick facts
Definition
Midazolam
Onset: 3-8 Minutes
Duration: 20-35 Minutes
Greater amnesia than diazepam
Faster onset than diazepam, lorazepam
Less pain than diazepam, lorazepam because water soluble
Term
Valium Quick Facts
Definition
Onset: 1-3 Minutes
Duration: 35-60 Minutes
More postoperative sedation than midazolam
Drug of choice in abolishing seizure activity -- due to quick onset
Pain and thrombophlebitis more common than midazolam
Delivery vehicle: Propylene glycol
Term
Contraindications to use of Benzodiazepines
Definition
Narrow angle glaucoma
Pregnancy
Term
Benzodiazepine Drug interactions
Definition
Increase blood concentrations and increase in elimination half-life
  1. Erythromycin
  2. Ketoconazole
  3. Rifampin
  4. Antiviral Medications
Term
Mechanism of action with opiods
Definition
hyperpolarization of cell membranes in CNS and peripheral NS
Term
Opioid Mu-1 Receptor Actions
Definition
analgesia, euphoria, miosis, urinary retention
Term
Opioid Mu-2 receptor actions
Definition
analgesia, decreased ventilation, bradycardia, constipation, dependence
Term
Opioid kappa receptor actions
Definition
analgesia, dysphoria, sedation, miosis
Term
Opioid delta receptor actions
Definition
analgesia, decreased ventilation, urinary retention, physical dependence
Term
Fentanyl time of onset
Definition
3.5-5min
Term
duration of Fentanyl action
Definition
30-60 min
Term
Problems with Meperidine
Definition
Demerol:
Active metabolites: Normeperidine
Lowers seizure threshold
Induces CNS excitability
Term
What is special about Remifentanyl
Definition
Ultra short acting mu agonist
Ester linkage renders it susceptible to hydrolysis by plama and tissue esterases
Rapid speed of onset: 1-2 minutes
Context sensitive T1/2: 3-6 minutes
Intense levels of analgesia of short duration
No residual opioid effects
Term
All opioid interactions
Definition
sedatives
cimetidine
Term
Propoxyphene drug interactions
Definition
Warfarin – increased bleeding
Carbamazepine(Tegretol), Metoprolol, Propranolol – increased blood levels of drug
Term
Fentanyl Drug interactions
Definition
Diltiazem – increased effects of opioid
Term
Meperidine
Definition
MAOIs
Term
Why isn't Vicodin and Codeine working?
Definition
deficiency in CYP2D6
Without CYP2D6, demethylation of codeine and derivatives to morphine cannot occur
Term
Name the Opioid Agonist / Antagonists
Definition
Pentazocine (Talwin)
Nalbuphine (Nubain)
Butorphanol (Stadol)
Term
Tidbits of Barbiturates
Definition
Produce sedative hypnotic effects via interaction with GABA
Depresses reticular activating system
Decrease transmission through sympathetic nervous system ganglia
Term
Methohexital
Definition
Brevital
Rapid induction – Maximal brain uptake within 30 seconds
Prompt awakening – redistribution to skeletal muscle and fat
Greater hepatic metabolism than other barbiturates
Term
Clinical effects of Methohexital
Definition
Deep Sedation – General Anesthesia
Not Anxiolytic
Hyperalgesic
Excitatory Effects
Respiratory Depression
Increased Heart Rate
Modest Decrease in BP
No Muscle Relaxant Properties
Term
Contraindications with Methohexital
Definition
Porphyria – May Provoke Attack
Epilepsy – Activates Foci
Asthma – Bronchospasm
Term
Adverese reations with Methohexital
Definition
Venous Thrombosis
Extravascular Injection
Intra-arterial Injection
Allergic Reaction 1:30,000
Term
Is propofol contraindicated with egg allergy?
Definition
No
Term
What is vehicle of Propofol?
Definition
Delivery in oil-in-water emulsion
10% Soybean Oil
2.25% Glycerol
1.2% Egg Phosphatide **Not contraindicated in egg allergy
Generic in metabisulfite vehicle **Does not attenuate vagal nerve stimulation induced bronchoconstriction
Term
Propofol Dosage
Definition
General Anesthesia
Induction: Adult 1-2.5 mg/kg
Peds 2.5-3.5 mg/kg
Monitored Ansthesia Care
Induction: Slow Injection .5 mg/kg
Incremental Bolus 5mg-20mg
Term
Ketamine Mechanism of action
Definition
Antagonist NMDA Receptor
Agonist Adrenergic Receptors
Antagonist Muscarinic Receptors CNS
Blocks Reuptake of Catecholamines
Agonist at opioid Sigma Receptor
Term
Ketamine Respiratory effects
Definition
Intact Reflexes
Maintenance FRC
Response to Hypercarbia Maintained
Bronchodilator
Term
Ketamine Cardiovascular effects
Definition
Increased HR
Increased BP
Increased CO
Direct Myocardial Depressant
Term
Contraindications to Ketamine use
Definition
Increased ICP
Open Globe
Hypertension***
Illicit Drug Use
Psychiatric Disorders**
Term
Ideal inhalational anethetic agent
Definition
Sufficient Potency
Nonpungent
No Adverse Respiratory Complications
No Adverse Cardiac Complications
Provide Muscle Relaxation
Minimal Metabolism
No Postemergence Side Effects
Reliable and Simple Delivery System
Economical
Term
What happens with Halothane+Epinephrine
Definition
Ventricular Dysrhythmias
Term
Sevoflurane organ toxicity
Definition
Compound A causes renal injury
with soda lime and less than 2L gas flow
No clinical studies have shown renal dysfunction (BUN, Creatinine)
Term
Second Gas Effect
Definition
High concentration of N20 augments uptake of a volatile anesthetic
Term
Diffusion Hypoxia
Definition
results from rapid elimination of N20, diluting alveolar oxygen and CO2
Term
Succinylcoline
Definition
1min onset
4min duration Dose 2-3mg/kg
Term
Action of anticholinesterase
Definition
inhibit action of cholinesterase so thee is more Acetyl choline to potentiate action potential
Term
Why do we give anticholinergic drug with Anticholinesterase
Definition
match onset of drugs effect on cardiac anticholinergic and antimuscarinic effects
Term
contraindications to use of Flumazinil
Definition
Chronic Benzodiazepine Therapy
Seizure Disorder
Tricyclic Antidepressant Toxicity
Term
What is a Good(ish) rescue antiemetic
Definition
Compazine
Term
Droperidol black box warning
Definition
Absolute Contraindication QT Prolonged Torsades des pointes
Initially Seen at >25mg, now reported at lower doses
12 Lead EKG Recommended Preop, 3 hrs postop
Term
What are Phenergan black box warnings
Definition
‘Caution should be used when administering phenergan to pediatric patients 2 years and older because of the potential for fatal respiratory depression.’
‘Do not give with other respiratory depressants’
‘Antiemetics are not recommended for treatment of uncomplicated vomiting in pediatric patients, and their use should be limited to prolonged vomiting of known etiology’
maybe for rescue antiemetic
Term
Serotonin uptake inhibitors
Definition
Ondansetron (Zofran)0.1mg/kg, or 4mg
Dolasetron (Anzemet) 0.35mg/kg, or 12.5mg
Term
NSAIDS – Aspirin Triad
Definition
Bronchial Asthma
ASA / NSAID Sensitivity
Nasal Polyposis
Term
Who has this NSAID-Aspirin triad?
Definition
Severe asthmatics: 20%
2-3% All Asthmatics
Term
What happens with NSAID - Aspirin triad?
Definition
Inhibition of cyclo-oxygenase with a shift to lipoxygenase pathway
Increased production of leukotrienes with sensitivity of the airway
Term
NSAID interations
Definition
Nephrotoxicity-- daily use for many years, increased if combined with acetaminofen, also assoc with caffeine and codeine
Lithium -- elevates levels
Elevates Methotrexate Levels Caution if >20mg/week
Displaces Coumadin from plasma albumin Warfarin + COX-2, Increased INR 16-20%
Warfarin + NSAID, Increased INR 50-80%
Disrupts mucosal protection
Elevates Digoxin Levels
Inhibits cardioprotective benefits of low-dose aspirin
Inhibit Antihypertensive action (with 6+day use) raise BP 5mmHg
Term
NSAID contraindications
Definition
Allergy
GI Ulcerations
Anticoagulant
Coagulopathy
Term
What is max Acetaminophen dose in Alcoholic
Definition
2g
Term
Clinical Features of Malignant Hyperthermia
Definition
Tachycardia (first sign 96%)
Increased ETCO2 (most sensitive sign)
Tachypnea (85%)
Rigidity (80%)
Cyanosis/Skin Mottling (70%)
Increased Temp (30%)
Arrhythmias
Term
What is amt of Dantrolene given
Definition
2.5-10mg/kg
Requires reconstituting of 20mg/60cc (kind of a pain)
Term
Treatment for Malignant Hyperthermia
Definition
Initiate body cooling, Iced IV, NG + ice packs
Consider NaHCO3 -- 1-2 mEq/kg – Need blood gas analysis to more accurately treat
Treat hyperkalemia with insulin, glucose
Treat ventricular dysrhythmias with IV procainamide
Term
What is diagnostic test for MH?
Definition
caffeine/halothane contracture studies on muscle biopsy
Term
What is Atypical Plasma Cholinesterase
Definition
Enzyme lacks the ability to hydrolyze drugs such as succinylcholine and mivacurium
Dibucaine number permits diagnosis
Term
What is Dibucaine number
Definition
Dibucaine Number: amide local anesthetic that inhibits normal plasma activity by 80%
Reflects the quality of plasma cholinesterase enzyme
Heterozygous – Sux lasts 20 min Incidence 1:480
Homozygous atypical – Sux lasts 60-180 min Incidence 1:3200
Term
Management of Laryngospasm
Definition
Lighten or Deepen Anesthetic Plane
Remove Noxious Stimuli
Suction Laryngopharynx
100% Oxygen, Positive Mask Pressure
Succinylcholine
Term
What is laryngospasm dose for succinylcholine?
Definition
Adults (0.1 mg/kg IV) Usually 10-20 mg Children (1.5 mg/kg IV) plus atropine (0.02mg/kg IV)
No IV: 4 mg/kg IM Deltoid
No IV: 3 mg/kg Submental Intralingual
Term
Define Postobstructive Pulmonary Edema
Definition
Airway Obstruction
Negative Intrathoracic Pressure
Increased Pulmonary Blood Flow
Increased Pulmonary Microvascular Pressure
Pulmonary Edema
Term
Clinical findings of Postobstructive Pulmonary Edema
Definition
Persistant, Often Small Oxygen Desaturation
Wheezing
Rales
Rhonchi
CXR: Bilateral perihilar patchy infiltrates
Term
Treatment of Postobstructive Pulmonary Edema
Definition
Supplemental Oxygen
CPAP
Diuretics
Consider Tracheal Intubation in Medically Compromised
Prompt Recognition results in Resolution in 12-24 Hours
Term
What causes "chest wall rigidity"
Definition
Caused by High Dose, Rapid Opioid Administration
Term
What is differential diagnosis for chest wall rigidity
Definition
Laryngospasm
Seizure
Term
What is treatment for chest wall rigidity
Definition
Reversal of Opioid (Narcan)
Term
Define Central Anticholinergic Syndrome
Definition
Caused by the use of Drugs with Anticholinergic Properties which cross the Blood-Brain Barrier
Scopalamine
Atropine
Antihistamines
Benzodiazepines
notglycopyrrolate
Term
What are Clinical Manifestations of Central Anticholinergic Syndrome
Definition
Central
Disorientation
Agitation
Hallucinations
Ataxia
Seizures

Peripheral
Tachycardia
Facial Flushing
Hyperpyrexia
Urinary Retention
Decreased Sweating
Term
What is treatment of Central Anticholinergic Syndrome
Definition
Physostigmine
Centrally Acting Anticholinesterase
Term
What are clinical signs of parasympathetic stimulation
Definition
Salivation, Sweating, Abdominal Colic, bronchospasm, bradycardia, nausea
Term
What are symptoms of cholinergic crisis?
Definition
nausea, vomiting, bradycardia or tachycardia, excessive salivation, sweating, bronchospasm, weakness, paralysis
Term
What is treatment of cholinergic crisis?
Definition
Atropine
10mcg/kg IV q3-10min until muscarinic symptoms disappear
Term
Dose of esmolol
Definition
0.5-2mg/kg IV (35-140mg)
Term
Dose of Hydralazine
Definition
0.1-0.2mg/kg IV (7-14mg) call it 10mg
Term
How much does an amp of Dextrose raise blood sugar
Definition
amp of D50 increase 75-100 mg/dl
Term
How does pediatric patient maintain blood pressure?
Definition
Heart Rate
Term
Chloral Hydrate possible complications
Definition
arrhythmia
laryngeal edema
gastric irritation
hypoglycemia
Term
Pediatric Dose of Oral Versed
Definition
0.5mg/kg (up to 15mg)
Term
Pediatric IM Ketamine dose
Definition
1.5-4.0 mg/kg
Often mixed with Midazolam 0.05-0.10 mg/kg
Can be mixed with Robinul 0.005 mg/kg
However Peak effect IM Robinul = 30 minutes Peak Effect IV Robinul = 1 minute
Term
Example of SSRIs
Definition
80% of new Psych prescriptions
Fluoxetine (Prozac)
Paroxetine (Paxil)
Fluvoxamine (Luvox)
Sertraline (Zoloft)
Citalopram (Celexa)
Veniafaxine (Effexor)
Term
Major interactions of SSRIs
Definition
CYP2D6 Inhibitors - Inhibit demethylation of codeine and derivatives to morphine
Delayed clearance of Benzodiazepines metabolized by hepatic oxidation
Oxycodone, Morphine, Dilaudid, unaffected
Term
Commonly used drug with Lithium interaction
Definition
NSAID: enhance renal reabsorption of Lithium and increase levels
Lithium has narrow therapeutic index
Term
Treatment modifications for patient taking TCAs
Definition
drug has anticholinergic effects
Increased heart rate, orthostatic hypotension, arrhythmias
limit epinephrine to 0.05mg (~3 carlules)
avoid Ketamine
Term
Side effects of Ginseng

recommendations
Definition
HTN, increased HR, nervousness, insomnia

ask patient to discontinue for 7day prior to appt
Term
Action of St. John's Wort
Definition
Used for depression and anxiety

Inhibits Serotonin, NE & Dopamine Reuptake, Synaptic Uptake of GABA & Binding to GABA Receptors
Term
Side effects of St. John's Wort
Definition
Xerostomia, Headache, Sedation, GI Irritation, Fatigue
Photosensitivity (at high doses)
Interacts with Antidepressants, Vasopressors, and SSRIs
May prolong Anesthesia
Discontinue 2-3 weeks pre-op
Term
Valerian action (herb)
Definition
used for insomnia, anxiety
Decreased uptake of GABA Inhibitory Transmitter -- will have more GABA effects
Term
Valerian interactions with our drugs
recommendations
Definition
Increase sedative effects of anesthetics, other CNS depressants, decrease BP

Taper off in weeks before surgery
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