1.  Quick induction/emergence

2.  Good analgesia

3.  Muscle relaxation

4.  Ability to make quick changes

5.  No S/E

*None of them meet this

1.  Preanesthetic:  calm pre-surgery

2.  Induction:  Inhalation or IV

3.  Maintenance:  Opioids, ketamine, BZD

4.  Reversal

Nitrous Oxide

1.  MAC

2.  Use

3.  ADEs (2)

1.  105%

2.  Induce euphoria

3.  Hypoxia, risk of abuse (never use > 70%)

Halothane

1.  Why does it have slow onset and termination?

2.  ADEs (2)

1.  High tissue solubility

2.  Arrhythmia; Hepatotoxicity

Isoflurane

1.  ADE (1)

2.  Good things about it (3)

1.  Airway irritant

2.  Maintains cardiac funciton; less respiratory depression; smooth emergence

Desflurane

1.  Fast what?

2.  Use

3.  ADE (1)

1.  Onset and termination

2.  Maintain anesthesia

3.  Airway irritant

Sevoflurane

1.  Use

2.  Good (3)

3.  Bad (1)

1.  Induction

2.  Less pungent (dec laryngospasm); fewer hemodynamic effects; rapid emergence

3.  Produces free fluoride so avoid in kids

1.  Barbiturates:  potent and rapid, but respiratory issues

2.  Propofol

3.  Ketamine

4.  Opioids

5.  BZDs

6.  NMBs

Local Anesthetics

1.  ____ block tranmission of nerve impulses

2.  ___ effect on consciousness

1.  Reversibly

2.  No 

Ester vs Amide Classification

1.  Bupivacaine

2.  Lidocaine

3.  Tetracaine

1.  Amide

2.  Amide

3.  Ester

1.  Lidocaine

2.  Mepivacaine

3.  Prilocaine

4.  Sulfites w/ epinephrine

1.  Tetracaine

2.  Bupivacaine

1.  Procaine

2.  Lidocaine

Vasopressors with locals

1.  Help what with duration

2.  Prevents systemic what

3.  Helps provide more

1.  Increase

2.  Toxicity

3.  Hemostasis

1.  Ischemic necrosis

2.  Neurotoxicity

3.  Cardiac toxicity

4.  Methemoglobenimia (Tx is methylene blue)

Max Safe Dose (mg/kg)

1.  Bupivicaine

2.  Lidocaine

1.  2

2.  4

Lipid Rescue from Local toxicity resulting in cardiac arrest

1.  Bolus

2.  Infusion rate

3.  What to do if not working

1.  1.5 mL/kg

2.  0.25 mL/kg/min or 15 mL/hr

3.  Repeat bolus or double infusion

1.  Nerve block use

2.  Epidural is a combo of what usually

1.  Post surgical pain or rib fracture

2.  Fentanyl and opioid

Assessment of pain

1.  3 unidimensional

2.  2 Behavioral

1.  Verbal rating scale; Numerical rating scale; Visual analogue scale

2.  Behavior pain scale; Critical care pain observation tool

Assessment of Sedation

1.  2 Subjective

2.  4 Objective

1.  Ramsey scale; Riker Sedation-Agitation Scale

2.  Heart rate variability; Lower-esophageal contractility; EEG; Bispectral index (BIS)

Usually use one from each category

Behavioral Pain Scale

1.  Numbers and trends

2.  3 Categories measured

1.  1-4 with 1 = less and 4 = most

2.  Facial expression; Upper limb; Compliance with ventilation

Ramsey Scale

1.  what is scale

2.  What is awake

3.  What is asleep

1.  1-6

2.  1

3.  4

Riker Sedation-Agitation Scale

1.  Scale

2.  Low, High

1.  1-7

2.  Low = 1:  narousable

High = 1:  dangerous agitation

1.  IV push (creates burden on nursing)

2.  Continuous infusion (may overmedicate)

3.  PCA (pt must be able to perform)

Fentanyl

1.  How much more potent than morphine

2.  Onset and duration

3.  Bad point

1.  75-100 

2.  Rapid and short

3.  Active metabolite

Morphine

1.  Lipid solubility

2.  Causes realease of what signaling molecule

3.  Duration

1.  Least lipid soluble

2.  Histamine

3.  4-12 hours

Hydromophone

1.  Potency compared with morphine

2.  Duration

3.  Active metabolites?

1.  6-8X

2.  Long

3.  No

1.  Locals

2.  APAP

3.  COX inhibitors

4.  Antiepileptics

5.  Ketamine

1.  Propofol

2.  Alpha-agonist

3.  Neuroleptics

4.  Benzos

5.  Other

Propofol

1.  MOA

2.  Analgesia?  Amnesia?

3.  Duration

4.  What is PRIS?

5.  Need to monitor what?

1.  Enhances GABA and antagonist at NMDA

2.  Little analgesic, but some antegrade amnesia

3.  Ultra-short acting

4.  Propofol Related Infusion Syndrome (PRIS):  Metabolic acidosis, rhabdo, elevated CK, renal failure, myocardial failure, arrhythmias, hyperlipidemia...most likely with prolonged infusion at high dose

5.  TGs...Change tubing every 12 h...1.1 kcal/mL

Dexmedetomidine 

1.  Good point

2.  Labeled for how much use?

3.  S/E

4.  Duration of action

1.  Easy arousability

2.  < 24 hours

3.  Hypotension and brady

4.  2-6 hours

Benzodiazepines

1.  What type of amnesia

2.  ____ sparing effect b/c of dec anticipatory effects

1.  Anterograde

2.  Opioid 

Midazolam

1.  Half-life

2.  Duration

1.  Very short

2.  2-6 hours

Lorazepam

1.  Potency of BZDs

2.  Active metabolite?

3.  Solvent

1.  Most potent

2.  None

3.  Propylene glycol so as low as 1 mg/kg can cause toxicity

Diazepam

1.  Duration

2.  How often is it used

1.  Long

2.  Limited use

1.  Neuroleptics

2.  Etomidate (procedural)

3.  Ketamine

4.  Barbiturates

5.  Benadryl

1.  ALI/ARDS

2.  Status asthmaticus

3.  Elevated ICP

4.  Tetanus

5.  Therapeutic hypothermia 

1.  Decrease O2 consumption

2.  Facilitates mechaincal ventilation

3.  Decreases muscle spasms

4.  Avoids barotrauma

1.  Pancuronium

2.  Pipecuronium

3.  Vecuronium

4.  Rocuronium

5.  Rapacuronium 

1.  Cisatracurium

2.  Atracurium

3.  D-tubocurarine

4.  Doxacurium

5.  Mivacurium 

Succinylcholine

1.  Only for what type of procedures

2.  Onset/Duration

3.  ADE

1.  Short, RSI

2.  Fast onset, short duration

3.  Hyperkalemia

Pancuronium

1.  Class

2.  Duration of action

3.  ADEs (2)

4.  Avoid in what (2)

1.  Aminosteroidal

2.  Long (60-90 min)

3.  Vagolytic; Histamine release

4.  Renal and hepatic failure

Vecuronium

1.  Class

2.  Length

3.  Good difference from pancuronium

4.  Avoid in

1.  Aminosteroidal

2.  Intermediate

3.  Not a vagolytic

4.  Avoid in renal and hepatic failure 

Rocuronium

1.  Class

2.  Duration

3.  Metabolite?

1.  Aminosteroidal

2.  Intermediate (30 min)

3.  Active metabolite

Atracurium 

1.  Class

2.  Special elimination

3.  Duration

1.  Benzylisoquinoliniums

2.  Hoffman (avoids renal and hepatic issues)

3.  Intermediate

Cisatracurium

1.  Class

2.  Duration

3.  Advantage over atracurium

4.  Elimination

1.  Benzylisoquinoliniums

2.  Intermediate

3.  Less mast cell degranulation

4.  Hofmann elimination

1.  Observation (lack of movement)

2.  Ventilator software (can detect overbreathing)

3.  Peripheral nerve stimulation (Train of Four [goal is 2-3])

1.  Analgesia

2.  Sedation (as deep as possible)

3.  Eye care to prevent eye drying damage

1.  Prolonged recovery so do not stop sedation and analgesia at same time as NMB

2.  Acute quadriplegic myopathy:  with long use, nutritional def, DDI

3.  Myositis ossificans:  Connective tissue; fibrobalsts; osteoblasts; supportive care and PT

4.  Tachyphylaxis

1.  High-alert med list

2.  Distinctive labeling

3.  Auxillary labels

4.  Avoid similar names

5.  Store separately 

6.  Limit availability 

1.  Only use as last option
2.  Never "prn agitation"

3.  D/C once moved to floor

4.  Never call "muscle relaxants"-->Paralyzing agents

5.  Use lowest dose possible

6.  Focused educaiton (providers on complications & risk) 

Assessing Pain goals for 

1.  Behavioral Pain Scale (BPS)

2.  Critical Care Pain Observation (CCPO)

Assessing Sedation goals

1.  Ramsey or Riker Sedation/Agitation Scale

1.  Ramsey:  2-3

2.  Riker:  3-4

Atropine 

1.  Dose

2.  When to use

3.  When not to use

1.  0.5 mg IVP up to 3 mg

2.  Brady

3.  Cardiac ischemia, heart transplant

Dopamine

1.  Use

2.  Infusion rate

3.  Must maintain

1.  Bradycardia

2.  2-10 mcg/kg/min

3.  Maintain intravascular volume

Isoproterenol

1.  Start

2.  Used to tx

1.  2-10 mcg/kg/min

2.  Brady

Adenosine

1.  Dose

2.  Contraindicated in

3.  When can you use

1.  6, 12, 12 followed by 20 mg flush fast push

2.  WPW

3.  Regular and monomorphic tachycardia (particularly narrow QRS)

1.  Procanamide

2.  Amiodarone

3.  Sotalol

Pulseless V Tach or V fib

1.  Order of stuff

1.  Shock

2.  CPR X 2 min

3.  Shock

4.  Epi (1 mg IVP Q3-5 min)

5.  Shock

6.  Amiodarone (300 mg load)

7. Shock

8.  Epi

9.  Amiodarone (150 mg bolus):  1 mg/min drip if converts

Vasopressin

1.  Dose

2.  When to use

1.  40 U IVP

2. Longer half-life version of Epi so use in a pt who responds to epi and then decompensates

Pulseless Electrical Activity/Asystole

1.  Looks like what?

2.  Treatment algorithm

1.  Sinus brady but w/o pulse

2.  CPR X2 min and 1 mg epi Q3-5 min

If shockable, switch to other route

1.  Hypovolemia

2.  Hypoxia

3.  Hydrogen ions

4.  Hypo/hyperkalemia

1.  Tension pneumothorax

2.  Tamponade

3.  Toxins

4.  Thrombosis

ETT drugs

NAVEL

1.  Naloxone

2.  Atropine

3.  Vasopressin

4.  Epi

5.  Lidocaine

Diagnostic PH

1. Pulmonary arterial pressure >

1.  Idiopathic

2.  Heritable

3.  Drugs and Toxin induced

4.  Persistant HTN of newborn

General Measures PH

1.  6

1.  Exercise

2.  Support group

3.  Don't get prego

4.  Travel may need O2

5.  Psychosocial support

6.  Influenza adn pneumovax

1.  Oral anticoagulants

2.  Diuretics

3.  Oxygen

4.  Digoxin

Epoprostenol

1.  How long stable

2.  Initial/Optimal dose

3.  What hapens if suddenly stopped

1.  8-12 hrs at room temp, must give by continious infusion pump

2.  2-4 ng/kg/min; 20-40 ng/kg/min

3.  Rebound PH and death

*$33,153

Iloprost

1.  Dosing route (2)

2.  Dose schedule

1.  Aerosol, intravenous

2.  2.5-5 mcg/inhalation 6-9 times daily

*$92,146

Treprostinil

1.  Stable how long

2.  Routes (4)

3.  Dose

1.  48 hrs room temp

2.  SC (preferred), IV, Inhaled, oral

3.  1-2 ng/kg/min; Optimal 20-80 ng/kg/min

$97.615

Bosentan

1.  Class

2.  Dose

3.  Monitoring

4.  Decreases efficacy of what

1.  Entothelin receptor antagonists

2. 62.5 mg BID for 4 wks, then increase to 125 mg BID

3.  LFTs monthly and HCt Q3 months

4.  Oral contraceptives

*$55,890

Ambrisentan

1.  Category

2.  Dose

3.  Monitoring

4.  Decreases efficacy of

1.  Endothelin receptor antagonists

2.  5 mg daily, if tolerated inc 10 mg daily

3.  LFTs monthly, Hct Q3M

4.  OC

*$56,736

Sildenafil

20 mg TID

*12,761