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Anesthesia Flashcards

1
Q

Types of Sedation

A

Conscious sedation - alleviates pain and anxiety without altering consciousness. Patient is able to maintain a patent airway and can respond to verbal commands.

Deep Sedation - light general anesthesia with decreased consciousness in which the person is not easily aroused. May be indistinguishable from general.

General Anesthesia - Depress the CNS causing complete loss of protective reflexes, ability to maintain a patent airway and respond to verbal commands.

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2
Q

5 Effects of General Anesthesia

A

Unconsciousness
Amnesia
Analgesia
Inhibition of autonomic reflexes
Skeletal Muscle relaxation.

No anesthetics currently available achieve all 5 alone.

Ideally should induce rapid, smooth, and reversible loss of consciousness.

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3
Q

Guedel’s Stages of anesthesia

A

Analgesia - Normal respiration, ocular movement, pupil size, reflexes, muscle tone, HR, BP. Used in labor, incisions, and minor operations

Delirium - Rapid respiration and HR, roving eye movements, dilated pupils, most reflexes, high BP, high skeletal muscle tone. Not used

Surgical Anesthesia - Respiration slows, eyes become fixed, pupil sizes from normal to dilated, loss of reflexes, decreased muscle tone, BP, HR. Stages 1 and 2 for most surgeries, 3 for some, 4 never attempted.

Medullary Paralysis - severe CNS depression resulting in death.

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4
Q

Anesthesia objectives

A

Minimize deleterious effects
Sustain homeostasis
Improve postoperative outcomes

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5
Q

General Hemodynamic Effects

A

Decreased MAP
Blunted baroreceptor reflex
Decrease in sympathetic tone.

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6
Q

General Respiratory Effects

A

Reduce or eliminate ventilatory drive and airway patency. Endotracheal intubation is necessary.

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7
Q

Reasons for Hypothermia

A

Low ambient temp, exposed body cavities, cold IV fluids, reduced thermoregulatory control, and reduced metabolic rate.

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8
Q

Causes of Nausea and Vomiting

A

Action of anesthetic on chemoreceptor trigger zone modulated by 5HT, histamine, ACH, DA, and NK1

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9
Q

Other Postoperative side effects

A

HTN
Tachycardia
Ischemia
Airway Obstruction

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10
Q

Balanced Anesthesia

A

Use of multiple classes to achieve the desired effect and depth given both preop and postop

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11
Q

Inhibitory Neuron Target of Anesthetics

A

GABAa receptor
Potassium channels

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12
Q

Excitatory Ion Channel Targets

A

NMDA receptors
Serotonin Receptors
ACH receptors

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13
Q

Parenteral Anesthetics

A

Methohexital
Etomidate
Ketamine
Propofol

Small Hydrophobic and lipid soluble

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14
Q

Parenteral Anesthetics that potentiate the GABA receptor

A

Etomidate and Propofol

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15
Q

Parenteral Anesthetics that inhibit the NMDA receptor

A

Ketamine

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16
Q

Redistribution: Three Compartment Model

A

Blood -> brain -> skeletal muscle.
Leads to termination of effects

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17
Q

Context sensitive half time

A

Elimination half time after discontinuation of a continuous infusion.

Ketamine, propofol, and etomidate show little increase in half life with prolonged infusion.

Redistribution, accumulation in fat, and drugs metabolic rate affect duration of action

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18
Q

Propofol

A

MOA: Potentiation of GABA, sodium channel blockade

Applications: Rapid onset and short duration. anesthetic induction, used in procedures for rapid return to preop mental status

Reduce dose in elderly due to reduced clearance, increase dose in young children due to rapid clearance

**Propofol infusion syndrome associated with prolonged high doses in young or head injured patients

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19
Q

Etomidate

A

MOA: Stimulates GABA

Applications: Rapid onset and short duration. anesthetic induction, used in procedures for rapid return to preop mental status

Preferred for patients at risk of hypotension or MI. Produces hypnosis and has no analgesic effects. INCREASED EEG ACTIVITY. DO NOT USE IN EPILEPSY

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20
Q

Ketamine

A

MOA: NMDA antagonist

Applications: Rapid onset and short duration. anesthetic induction, used in procedures for rapid return to preop mental status

Suited for patients with hypotension, asthma, and pediatric procedures. Increases HR, BP, CO, CBF, and ICP. Mental side effects like delirium and hallucinations

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21
Q

Methohexital and Thiopental

A

MOA: Stim GABA

Application: Anesthetic induciton

Respiratory and EEG depressant

Rapid clearance

Possible inflammatory or necrotic reaction with injection

22
Q

Inhalation Anesthetics

A

Fluranes and NO

Most dangerous drugs in clinical use due to narrow therapeutic window

Fluranes are liquids are room temp, NO is gas

Increase in solubility slows induction of anesthesia. NO less soluble than fluranes

23
Q

Inhalation Uptake

A

FA approaches FI fastest for the least soluble agents.

Low blood solubility leads to rapid concentration increase

Greater blood solubility causes more molecules to dissolve in the blood before the partial pressure changes, causing the arterial pressure to increase less rapidly

24
Q

Effect of ventilation on FA/FI

A

To accelerate induction increase the inspired anesthetic pressure.

Increase tidal volume and respiratory rate

Greater increase in FA/FI ratio with an increase in ventilation for halothane when compared to NO

25
Minimum Alveolar concentration
Concentration of inhaled anesthetic needed to eliminate movement in 50% of patients stimulated by incision. Inverse is a measure of potency MAC is small for potent and large for weak. NO cannot produce anesthesia alone
26
Elimination
Most soluble take longer to clear. Insoluble prefer gas phase and rapidly diffuse to alveoli and are eliminated Ventilation is the determining variable.
27
Toxicity of Inhalation Anesthetics
Acute: nephrotoxicity, hematotoxicity, genetic hyperthermia, hepatotoxicity. Chronic: Mutagenicity, teratogenicity, reproductive effects, cardiogenicity.
28
Isoflurane
MOA: Increases GABA release and glutamate reuptake decreasing motor function. Application: Maintenance of anesthesia Highly volatile at RT. Decreases ventilation and RBF. Increases CBF. Hypotension and increased coronary blood flow, decreased myocardial O2 demand. Decreased baroreceptor reflex.
29
Enflurane
MOA: Positive allosteric effector of GABA receptor. Application: Maintenance Also volatile with slow induction. Decreased arterial BP and decreased contractility. Possible increased ICP and seizure
30
Sevoflurane
MOA: not fully understood, likely membrane hyperpolarization through GABA Application: Anesthetic induction for outpatient surgery. Ideal induction agent. Decreased AP and CO, so preferred for patients with ischemia. Sevoflurane + CO2 absorbent soda lime is nephrotoxic.
31
Desflurane
MOA: Same as sevoflurane Application: Same as sevoflurane, although not preferred over it. Highly volatile, nonflammable in mixtures of air of O2. Airway irritant
32
Nitrous Oxide
MOA: Unknown Weak anesthetic with analgesic effects Used as adjunct. Expands volume of air containing cavities, so avoid in ear or bowl obstructions or introcular bubbles. Administer 100% O2 rather than air when discontinuing to avoid hypoxia. Controversial due to potential changes in DNA and protein synthesis
33
Neuromuscular Blocking Agents MOA
Nondepolarizing: prevents the opening of sodium channel when bound to the receptor Depolarizing occupies the receptor and blocks the channel.
34
Neuromuscular Blocking Agents Uses
Surgical relaxation Endotracheal intubation Control of ventilation Treatment of convulsions, although they don't cross the BBB.
35
Assessment of Neuromuscular Transmission
Nondepolarizing: Fade Depolarizing phase I: Diminished Depolarizing phase II: Fade
36
Succinylcholine
MOA: Persistent depolarization at NMJ Rapidly metabolized by plasma cholinesterase Arrhythmias. hyperkalemia, intraocular and abdominal pressure, and postop muscle pain are possible side effects.
37
-curium/curonium
MOA: Competitive antagonist at nACH receptors Application: relaxation for surgical procedures Action is usually antagonized by Sugammadex or and ACH inhibitor when the effects is no longer desired. Toxic Effects: Prolonged apnea
38
Sugammadex
MOA: Noncompetitive inhibition of rocuronium and vercuronium through encapsulation Used to reverse neuromuscular blockade. Side effects: Bradycardia, hypersensitivity, recurrence of neuro blockade, headache, vomiting, nausea.
39
Benzodiazepines
Midazolam Diazepam Lorazepam Enhance GABA Used to anxiolysis, amnesia, sedation. Midazolam is most commonly used followed by the other two
40
A2 agonists
Dexmedetomidine Short term sedation of critically ill adults or sedation prior to procedures in non-intubated patients Side Effects: Hypotension and Bradycardia
41
Opioids
Reduce anesthetic requirement and minimize hemodynamic changes due to painful stimuli Primary analgesics during perioperative period. Administered intrathecally and epidurally.
42
NSAIDs
Used for minor surgical procedures to control postoperative pain
43
Oxygen
Used to reverse or prevent hypoxia Excessive use decreases ventilation HR and CO decrease Can irritate mucosal surfaces so humidified O2 should be used.
44
Carbon Dioxide
Insufflation during endoscopic procedures Flooding surgical field during cardiac procedures Adjusting pH during bypass Highly soluble Respiratory acidosis Increases CO, HR, and BP
45
Local Anesthetics
MOA: Bind inside ion channel and block sodium ion entrance to prevent depolarization Extradural injection = epidural Caudal block = needle inserted into caudal canal via sacral hiatus Peripheral nerves = perineural block CSF = Spinal block
46
Local Anesthetics Absorption
Dependent on dosage, site of injection, drug tissue binding, local tissue blood flow, and physiochemical properties of the drug. More lipid soluble = more potent and longer duration of action + longer time to achieve effect. Peak serum values vary based on site of injection. Intercostal is highest while femoral and sciatic are lowest
47
Local Anesthetic Toxicity
CNS - sedation, lightheadedness, visual and auditory disturbances Cardio - Negative effects on conduction and overall function Neural: Potential neruotoxicity leading to neural injury. Transient Neurologic symptoms: possible transient pain or dysthesia
48
Short Duration Local Anesthetics
Lidocaine Prilocaine Mepivacaine Duration 1-2h/ 2-4h with epi Prilocaine and Mepivacaine pose a risk of methemoglobinemia
49
Longer Duration Local Anesthetics
Bupivacaine Ropivacaine Levobupivacaine Duration 3-6 h Possible cardiovascular collapse
50
Popular Dental Anesthetic
Articaine
51
Very Short Acting Local Anesthetics
Chloroprocaine Procaine 30-60 min/ 60-90 with epi Procaine not used epidurally
52
Spinal Anesthetic
Tetracaine

pharm 2 (11 decks)

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