Anesthesia

Question 1

MOA propofol

Answer 1

Increases affinity for GABA-GABAa receptor> prolonged opening of Cl channel> hyper polarized nerve membrane> inhibitory effect on CNS>induction/maintenance of GA

May also be related to reduced glutaminergic activity through NMDA receptor blockade

Other effects:
CNS- decreased cerebral metabolic rate, oxygen consumption, ICP
CVS- decreased SVR, preload and contractility
RESP- decreased hypoxic/hypercapnic resp drive and decreased upper airway reflexes

Question 2

Indications for propofol

Answer 2

Induction/maintenance of GA

Question 3

Contraindications of propofol

Answer 3

Hypersensitivity (including eggs or soy)
<3YO
3rd trimester

Question 4

Propofol dosage

Answer 4

RSI
Stable: 1-2.5mg/kg
Unstable: 0.5-1mg/kg

Continuous infusion 25-100mcg/kg/min (typically start at 50-60, 30-35for geris)

Bolus: Use program bolus dose&time (1mL= 10mg or 20mg depending on concentration), follow with increased dose rate so you’re not swinging wildly. Typically 10-20mg (Rico said 20-40)

Question 5

Propofol formulary

Answer 5

2%= 2000mg/100mL= 20mg/mL
1%= 1000mg/100mL= 10mg/mL (CTS)

Question 6

Propofol pharmacokinetics

Answer 6

Onset 30sec
Duration 3-10min

Question 7

MOA Fentanyl

Answer 7

Analgesia- mu receptors in brain and spinal cord decrease release of pain neurotransmitters (glutamate, substance P, CGRP)

Respiratory and cardiac depression- mu receptors in brainstem

Other effects see Calgary Guide to Understanding Disease- Anesthesia

Question 8

Fentanyl Indications and dosages

Answer 8

RSI: 1-4mcg/kg (or 50-200mcg)

Maintenance infusion: start at 25-50mcg/hr or 50-100mcg/hr (higher tolerance, painful state) up to 300mcg/hr.
BOLUS: 25-50mcg

Analgesia loading dose 0.5-1.0mcg/kg (IV/IM/IO) or 1.5-2.0mcg/kg (IN)

Question 9

Fentanyl formulary

Answer 9

500mcg/50mL= 10mcg/mL
Compatible with d5w or NS

Question 10

MOA Rocuronium

Answer 10

NDNMBA
Competitive antagonist of ACh at post synaptic nicotinic receptors on muscles— skeletal muscle paralysis

Other effects:
2. Vagolytic effect- blockage of vagal muscarinic receptors in SA—tachycardia
3. Anaphylaxis— IgE antibodies attach to ammonium and components of NMBAs or non-immunologic mast cell degranulation—> release of histamine—> bronchospasm and/or hypotension

Question 11

Contraindications and side effects of Rocuronium

Answer 11

Allergy
Caution: liver failure (double half-life) and renal failure

Question 12

Rocuronium dosage

Answer 12

RSI: 0.6-1.2mg/kg
Maintenance: 1mg/kg/hr (depends) Or 50mg aliquots q 30-45min

Question 13

Rocuronium formulary

Answer 13

CTS: 50mg/5mL (10mg/mL) x4 vials =200mg
Standard infusion 2mg/mL
Compatible with NS, D5W, LR

Question 14

Rocuronium effects on AAAA, Neuro, Resp

Answer 14

Causes areflexia and apnea other AAA no and neuro no.

Question 15

Propofol effects on AAAA, Neuro, Resp

Answer 15

Amnesia yes*
Dose-dependent hypotension and RR depression
Neuro- sedative/hypnotic

Question 16

Fentanyl effects on AAAA, Neuro, Resp

Answer 16

Causes Analgesia, areflexia (blocks pain and therefore reflex), autonomic stability (blunts sympathetic drive).

Hypoventilation/apnea
Neuro- DLOC

Question 17

MOA Succinylcholine

Answer 17

DNMBA
1. ACh mimic- agonist at nicotinic ACh receptors in muscles— continuous end-plate depolarization— inactivation of Na+ channels— prevents repolarization and additional action potentials—> skeletal muscle paralysis

2. Continuous end-plate depolarization leads to fasciculations and myalgias
3. Agonist at nicotinic receptors in parasympathetic ganglia, sympathetic ganglia, and muscarinic receptors in SA node— low dose—> parasympathetic, high dose —>sympathetic

Question 18

Contraindications and side effects of Succinylcholine

Answer 18

Avoid in burns(>24hrs), CVA, neuromuscular disorders S/E: Malignant Hyperthermia, muscle pain, hyperK, bradycardia

Question 19

Succinylcholine dosage and formulary

Answer 19

1.0-1.5mg/kg
CTS: 400mg/20mL (20mg/mL) x 2 vials= 800mg

Question 20

Succinylcholine effects on AAAA, neuro and resp

Answer 20

Causes areflexia and apnea, may cause bradycardia.

No effects on amnesia, analgesia, or LOC.

Question 21

MOA Ketamine

Answer 21

Opioid agonist, NMDA antagonist, muscarinic antagonist, enhances monoaminergic transmission

Question 22

Contraindications and side effects of Ketamine

Answer 22

allergy, conditions that would worsen with HTN* (depends)
S/E: hypersalivation, prolonged emergence (stage II), CARDIAC DEPRESSANT in catecholamine depleted states

Question 23

Ketamine dosing (GA only) and formulary

Answer 23

RSI: 0.5-2mg/kg

Maintenance: half induction dose/hr or 0.5mg/kg/hr or BOLUS: 25mg
1000mg/100mL=10mg/mL
Compatible with D5W, NS

CTS: 100mg/2mL x5 and 500mg/10mL x2= 1500mg

Question 24

Ketamine effects on AAAA, Neuro and Resp

Answer 24

AAAA yes, but balance between sympathetic enhancer vs. cardiac depressant
Neuro- DLOC
Resp- no effect (other than bronchodilation)