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Pain Control II > 2/27 - GA > Flashcards

2/27 - GA Flashcards

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1
Q

IV sedation definiti

A

administration of a drug which results in the depression of the CNS

the goal is to produce a state of sedation in which the patient
maintains protective reflexes, and the respiratory and caridovscular systems are minmially affected

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2
Q

rapid onset of IV?

A

yes - the arm to brain circulation is approx 20-25 seconds

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3
Q

advantages of IV sedation

A
  1. rapid onset
  2. titration
    - the drug dosage may be tailored
    - suitable level of sedation
    - shorter recovery periods
  3. continous IV infusion
    - patent vein is maintained throughout procedure
  4. side effects of nausea and vomiting
    - rare when administrated as suggested (titrated)
  5. salivation
    - control of salivary secretions is possible through the administration of antcholinergics
  6. gag reflex
    - is diminished
  7. diminish motor disturbances- diminish seizure activity
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4
Q

titration

A

titration

  • the drug dosage may be tailored
  • suitable level of sedation
  • shorter recovery periods

advantage of IV sedation

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5
Q

titration

A

titration

  • the drug dosage may be tailored
  • suitable level of sedation
  • shorter recovery periods

advantage of IV sedation

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6
Q

disadvanta ges of IV

A

venipuncture is necessary

complications may arise at the site of venipuncture

monitoring **– must be more intensive than that rewuired in most other conscious sedation techniques

revoery not complete – Escort is needed

most IV agents CAN NOT BE reversed – have to be metabolized first

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7
Q

indications for IV sedation

A
  1. anxiety and fear
  2. mentally or physically disabled
  3. age - infants and children
  4. amnesia
  5. med compromised patients
    - angina
    - HBP
    - previous myocardial infarcatin
    - previous cerebrovascular accident
    - epilepsy
  6. control of secretions
  7. analgesia
  8. diminished gagging
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8
Q

contraindications so IV sedation

A

lack of proper training

pregnancy - relative contra

  1. hepatic disease due to liver metabolism
  2. thyroid dysfunction
    hyper - thyroid strom could develop

low thyroid - may not metabolize as well

  1. adrenal insufficiency - crisis
  2. adrenal insufficiency

patients receiing MAOI’s or TCA’s
- go into seratonin syndrome

extremley obese

inadequte veins

allergy to medications

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9
Q

preganncy in IV sedaion

A

relative contraindication – bcause most CNS depressants cross the placenta – into the fetus and may produce birth defects in the developing fetus

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10
Q

briefly exaplin anesthesia as a continuum

A

can eassily move from a deep sedation to GA

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11
Q

ultra-light GA

A

outpatient general anesthesia using IV barbiturates

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12
Q

advantages of general anesthes eia

A

cooperation not essential

patient is unconscious

patient does not respond to pain

amnesia is present (they dont remember)

GA may be the only technique that will prove successful for certain patients

rapid onset

tritration is possible

success rate is 100%

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13
Q

disadvantages of GA

A

patinet unconscious

protective reflexes are depressed

vital signs are depressed

advanced training

anesthesia team is required

special equipment

recovery area must be available

intra-operative and postanestetic complications are more common

patient receiving GA must receive nothing by mouth for 6 hours beore the procedure

patients receiving GA must be evaluated more extensively preoperatively than patients receiving minimal or moderate sedation

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14
Q

contraindications to GA

A

lack of trining

lack of adequatley trained personnel

lack of adequate equipment or facilitities

ASA IV and certain ASA III medically compromised patients

Hx of poliomyelitit in which chest muscles have been involved

Hx of Myasthenia gravis

obese

patients with significantly decreased cardiac and / or pulmonary reserve

patients with a history of malignant hyperthermia

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15
Q

ASA types contraindicated in GA

A

ASA IV and some ASA III

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16
Q

indications for GA

A

extreme anxiety o fear

mentally or physiclly disabled

age - infants and children

short or long traumatic procedures

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17
Q

benefits of outpatient GA v s inpatient

A

economics - cost is cheeper outpatient

psychological benefits

reduced exposure to nonsocomial infections

parental preference

inpatient is in hospital

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18
Q

types of GA

A

in - office outpateitn GA
- IV anesthesia - less than 30 minutes
conventional operating theater type of GA more than 30 mins - less than 4 hours

inpatient type

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19
Q

outpatient GA IV using?

A

propofol or barbiturates

N2O2-O2 (along with the case)

benzodiazepine / versad

opiods - like fentynol

LA* - block of the responses

  • like what you see in the oral surgery clinic
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20
Q

outpatient GA -conventional type of operating room GA

A

used in cases 30 mins to 4 hours

patient undergoes same GA prep as the inpatient

limited to ASA I and II – selected III

completed training in anesthesiology

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21
Q

inpatient GA

A

patient admitted to hospital prior to procedure

undergoes workup to determine risk , undergoes procedure and then remains in hospital post-op

ANesthesiologist is responsible for the administration for the anesthetic* (vs outpatient - you have to be certified)

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22
Q

armamentarium

A 
anesthesia machine
IV equip
ancillary anesthesia equipment 
monitoring equip 
emergency equipment and drugs
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23
Q

ancillary anesthesia equipment

A

face masks and appropriate connectors

laryngoscopes, blades

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24
Q

monitoring equipment

A

stethoscopes

  • precordial
  • pretracheal
  • esophageal
pulse oximeter
end-tidal CO2
blood pressure cuff
ECG
temperature
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25
TIVA
total inervenous anesthesia - a continous IV infusion is commonly used for all general anesthetic procedures - indwelling catheters are preferred - tubing and bags of IV solution are requred - disposable syringes and needles should be available - adhesive tape
26
endotracheal tubes and connectors
part of armamentarium
27
LMA
laryngeal mask airways - acts like an endotracheal tube does not get fully patent airway - used in the field more
28
Bispecteral electroencephalographic monitoring
BIS monitoring | -
29
intra arterial blood pressure
degree of accuracy is great but not really needed during outpaient sedation indicaed in both general anesthetic proccedures involving greater degree of risk - neuro or cardiac surgery and when degree of risk presented by the patient (ASA IV or V) is significant
30
types of benzodiazepines used
diazepam - valium midazolam - versed
31
mechanism of benzo'
becoming less excitebale binds to stereospecific benzo recepetors on the postsynaptic GABA neuron at several sites within the central nervous system, including the limbic system, reticular formation increase inhibitory effect of GABA by increased neuronal excitablility - INCREASE PERM TO CHLORIDE IONS - hyperpolarization -- less excitable state
32
contraindications to benzo
allergy to diazepam acute narrow glaucoma and wide angle glacuoma
33
contraindications to benzo of valium (diazepam)
allergy to diazepam acute narrow glaucoma and wide angle glacuoma psychosis pregnancy
34
versed aka
midazolam - benzo
35
used more versed vs valium
versed -- need to know the comparisons of these versed is more potent
36
barbiturates? | their indication
not used as much today but served a lot in terms of sedative drugs can produce any level of sedation ranging from light sedation through hypnosis - GA , coma and death indication -- induction and maintenance of GA anesthesia for short procedure
37
pentobarbital
barbitruate classified as short acting barbiturate IV sedation seizure control effects and side effects - reduces cerebral metabolism - modest decrease in blood pressure - temporary respiratory depression - hangover effect
38
reversal agent to benzo
flumazenil
39
flumazenil
reversal agent to benzo contraindicated in - allergy to benzo or flumazenil - if being treated for stuff on benzo's like status epilepticus, or control of intracranial pressure
40
opioid antagonist
naloxone
41
most commonly used inhalation
nitrous
42
nitrous oxide not used for GA? what is its use
not strong enough -- not potent enough MAC is not high enough to get to general - it is 104-105% second gas effec**
43
primary function of nitrous oxide in GA?
SECOND GAS EFFECTS in GA it is used to potentiate the actions of the other more potent drugs (IV or inalation) and thus permits a smaller dose or lesser concentration of this drug needed to produce the desired level of GA
44
neuroleptanesthesia | produced how?
type of GA that is produced by the administration of neuroleptic drug - and an opioid are administered together characterized by - sleepiness, psychological indifference to environment, no voluntary movements, analgesia, satisfactory amnesia produced by administering? ***(droperidol) = neuroleptic drug (does have black box warning) - opiod - fentanyl - nitrous oxide -oxygen - muscle relaxant
45
dissociative anesthesia
type of GA - dissociative anesthesia and analgesia as produced by KETAMINE patient appears to be awake maintain many reflexes unaware of,or dissociate from the environment eyes open - may see nystagmus
46
disadvantages of ketamine / contraindications
used in dissociation anesthesia (type of General) increased heart rate, blood pressure and intraoclular pressure eye movements and nystagmus can occur no antagonist is available for it can produce a confused state, associated with unpleasant dreams and frightening hallucinatins (more common to occur with adults ) -- so use with a benzzo
47
contraindications to ketamine
intraocular surgery, patietns with history of increased CSF pressure, CVA, psychiatric problems , and HTN
48
four mechanisms of muscle relaxants
muscular blocking agents - interfere with the transmission of impulses from motor nerves to muscles at the skeletal neuromuscular junction 1. deficiency block 2. nondepolarizing block 3. depolarizing block 4. dual block
49
no drug ever exerts a single action?
true
50
william harvey
provided much of the groundwork for the future of IV medication - stating that there was a continuous circulation of blood within a closed system showed that because of valves in heart and veins - blood flow within circulatory system was unidirectional
51
jorgensen
first to use IV route for premedication | combo of barbiturate (phentobarbital and opioid (meperidine) and scopolamine
52
mcantosh blade is ? | miller blade is?
mcantosh is curved miller is straight
53
miller straight blade into the oral cavity?
underneath the epiglottis
54
mcantosh blade into the oral cavity?
curved so want it -- go into velecula NOT under the epiglottis do NOT rotate on it -- b/c if you do then you can hit the maxillary teeth
55
oropharyngeal and nasopharyngeal airways?
if using oropharyngeal airway -- patient has to be out - if semi-conscious they can choke on it nasopharyngeal airway - semi-conscious measure from corner of mouth to angle of the mandible
56
pretracheal stethescope
around the trachea - and can pick up on breath sounds - gurgling obstruction early different wave form
57
esophageal stethescope
for patient already intubiated and able to hear heart sounds better as well can add a thermometer and get a core temperature reading
58
why temp
making sure patients -- especially younger populations are not going through malignant hypothermia
59
Not commonly used monitors
EEG arterial blood pressure Central venous pressure (CVP) - invasive and goes into the atrium collection and measurments of urine output
60
EEG
gets a number shows the person is sedation electroencephalogram identifying hypnotic effects of anesthersia BIS (bispectral) index - continuous EEG parameter that ranges from awake - no drug to effect value of 95-100
61
intra arterial blood pressure
CONTINOUS blood pressure artery radial artery more in the obese patient degree in accuracy is great but not really needed during outpatient indicated in GA involving greater risk - neuro or cardiac surgery or when patient is ASA III NOT needed during outpatient setting -
62
opiod agonist / antagonisht?
pentazocine | nalbuphine
63
anticholinergics
atropine | scopolamine
64
antidotal drugs
flumazenil - reverses benzo's
65
indications for valium
oral med for preopertative dental anxiety sedative component in IV sedation in oral surgery skeletal muscle relaxant medical - management of anxiety disorders, alcohol withdrawl symptoms, skelteal muscle relaxant and convulsive disorders
66
eyelid halfway over pupil?
veral sign | know in good state of relax
67
indications for versed
Miazolam ( m =more - using it more) dental - sedation component in IV sedation in OS patients syrup formulation used in children to help alleviate anxiety before dental procedure medical - preoperative sedation and provides IV ssedation prior to diagnostic or radiographic proceddures
68
amnesia produced in midazolam and diazepam
anterograde better in midazolam / versed -- "need to foreget - versed"
69
biotransformation of midazolam and diazepam
midazolam = 1.7- 2.4 hours vs diazepam = 31/3 hr
70
which benzo has pain on injection and why?
diazepam and b/c of its medium - of propylene glycol * so put into bigger vein so it does not irritate it as much *none in midazolam because versed / midazolam is WATER BASED
71
what benzo to use when the patient needs to forget?
VERSED -- midazolam
72
respiratory system effect of diazepam vs midazolam
diazepam causes more depression
73
analgesic with the benzo?
NO
74
sedation effect with midazolam and diazepam
higher levels of sedation with diazepam / valium | than midazolam / versed
75
biggest reason why people started using midazolam over diazepam
because of the differences in the half lives of them active metabolite half life of midazolam is less than that of diazepam *but versed is more potent
76
contraindications for barbs
``` allergy uncontrolled pain addiction to sedative hypnotics porphyria respiratory diseasae with dyspnea or obstruction ```
77
reversal agent to barbiturates?
no
78
pharmacology of barbs
no effect on pain threshold except in doses that affect level of consciousness anticonvulsant properties eliminated by biotransformation in the liver and excretion through the kidneys
79
indications for opiod agonists
supplementatino of GA Pain releif premedication
80
conraindications for opioid agonists
allergy COPD and decrease respiratory reserve patietns receiving MAO inhibitors within the previous 14 days increased inracranial presure
81
side effects of opiod agonist
``` resp deprssion nausea / vomitt hypotension drowsniness histamine release ```
82
fentanyl aka? what type? indications
sublimaze - opiod agonist dental - adjunct in preoperative IV sedation in patients going surgery medical - sedation - releief of pain, preop med, adjunct to general or regional anesthesia, management of chronic pain
83
side effects of fentanyl / submlimaze
rapid IV infusion may result in skeletal muscle and chest wall rigidity , impaired ventilation, respiratory distress, apnea, bronchoconstriction, laryngospasm INJECT SLOWLY over 3-5 minutes, non-depolarizing skeletal muscle relaxant may be required
84
dosage of flumazenil
benzo antagonist .2mg IV repeat 1 minute interval average reversal dose is .2mg max dose is 1.0 mg given IV do NOT give patients being treated for status epilepticus, or control of intracranial pressure (can increase it)
85
naloxone hydrochloride
opiod antagonist - contraindications opiod dependence and allergy dose is .1 to .2 mg IV over 2-3 minutes average reversal dose is .4 mg max dose is 1.2 mg for adult
86
types of GA
1. inhalation anesthetics - most frequently used means of producing general anesthesia 2. neuroleptanesthesia 3. dissociative anesthesia
87
halothane
inhalation MAC of .75% - pretty potent - rarely used disadvantages - myocardial depression, produces cardiac dsyrhthmias, sensitization of myocardium to actions of catecholamines , potent urine relaxant, possible hepatic necrosis have to be aware if using this with vasoconstrictors
88
enflurane
MAC of 158% compatible with epinephrine good for asthmatics advantages - pleasant odor, rapid inductin, nonirritating, BRONCHODILATOR, good muscle relaxatnt, no dysrrthmias, non an emetic, nonexplosive and non flammable diasdvantage -
89
isoflurane
MAC 1.28% pleasnat odor, rapid inductino, nonirritating , bronchodilatort, muscle relaxant, stable cardaic rhythm, compatible with epi, disadvantages - myocardial depression, depressed BP, postanesthetic shivering, not given to decreased renal renal function
90
sevoflurane * noted for?
MAC 1.71% used fo outpatient more LOW SOLUBILITY , rapid induction and emergence from anesthesia, less irritating to the airway *commonly used inhalation anesthetic in ambulatory dental anesthesia cases
91
desflurane
irritating - unpleasant odor - so NOT RECOMMENDED for induction because of this MAC 4.6-6.0% rapid onset and recovery - recovery seems to be advantage
92
patent airway can be maintained with ketamine? advantages?
yes non irritating to bloos vessels and tissues, muscle tone is preserves and laryngeal and pharyngeal reflexes are not depressed can use in children used in patietns who are hemodyanmically unstable or hypovolemic - b/c it can increase blood pressure can be used with asthmatic patients
93
increase salivation?
ketamine
94
dysphoric emergence with?
ketamine -- so use a benzo with it greater chance happening if older
95
antagonist to ketamine
no
96
indications for propofol
induction of anesthesia maintenaince of anesthesia postop antiemetic mechanism of action - hindered phenolic compound - UNRELATED to any other barbs, opioid, benzo o careful in older adults - but only major disadv is pain on injection
97
deficiency block
muscle relaxent - synthesis and/ or transmission of acetycholine is interfered with - neomycin, kenamycin, clostridiu botulinum
98
non- depolarizing block
muscle relaxant - COMPETITVE BLOCK - drug attaches to cholinergic receptors , preventing acetycholine from attaching to the receptor (curare, pancuronium
99
depolarizing block
muscle relaxant | - dru acts in a manner similar to acetycholine but for prolong period of time (succinycholine)
100
dual block
muscle relaxant DESENSITIZATION BLOCK - the membrane is depolarized (phase 1) and then is slowly repolarized drug enters into the fiber and acts as a nondepolarizing agent (phase II)
101
pre-oxidate | then
relaxe - versed then fentynol ``` breathing then propofol (put to sleep) ``` then muscle relaxant laryngoscope ready
102
purposes of record keeping
1. trend plot of vital 2. as an aid to the clinicians memory 3. as a documentation of a patients response to the administration of drugs and the operative procedure 4. nonclinically - as a legal document
103
eating and drinking before surgery
nothing after midnight if infant - no solid food or milk 6 hours before - clear liquids up to 4 hours before

Pain Control II (15 decks)

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