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Anesthesia Agents/ Adjuncts/ Reversal Flashcards

1
Q

What is ASA Score?

A

Rates physical status of patient assessed prior to receiving sedation/ anesthesia.

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2
Q

All about ASA

What are the different ASA Scores/ levels?

A

ASA 1 Healthy Pt
ASA 2 Healthy Pt with mild systemic disease (BMI>30)
ASA 3 Pt with severe systemic disease that limits activity
but not incapacitating (BMI>40)
ASA 4 Pt with severe systemic disease that is constant
threat to life

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3
Q

What are the different ASA Scores/ levels?

A

ASA 5 Pt not expected to survive without urgency
ASA 6 Pt brain dead to OR for organ harvest
ASA E Any emergency surgical procedure

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4
Q

What are examples of ASA 2?

A

Mild diseases only without substantive functional limitations. Current smoker, social alcohol drinker, pregnancy, obesity (30<BMI<40), well-controlled DM/HTN, mild lung disease

https://www.asahq.org/standards-and-practice-parameters/statement-on-asa-physical-status-classification-system

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5
Q

What are examples of ASA 3?

A

Substantive functional limitations; One or more moderate to severe diseases. Poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, history (>3 months) of MI, CVA, TIA, or CAD/stents.

https://www.asahq.org/standards-and-practice-parameters/statement-on-asa-physical-status-classification-system

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6
Q

What are examples of ASA 4?

A

Recent (<3 months) MI, CVA, TIA or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, shock, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis

https://www.asahq.org/standards-and-practice-parameters/statement-on-asa-physical-status-classification-system

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7
Q

What is general anesthesia?

A

State of reversible unconsciousness where protective reflexes are partially or completely lost.

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8
Q

What is monitored anesthesia care?

A

Relaxed, **non-paralyzed state **of analgesia and sedation
Pt maintains airway independently
Responds to verbal commands
!Administered by anesthesiologist/ CRNA

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9
Q

What is the 1st stage of anesthesia?

A

BEGINS with initiation and
ENDS with loss of consciousness

Protective reflexes maintained
!Patient feels conscious but drowsy
!Patient can follow simple commands
!Perception of pain is diminished

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10
Q

What is the 2nd stage of anesthesia?

A

BEGINS with loss of consciousness and
ENDS with loss of protective reflex

!Delirium/ Excitation (highest risk stage)
!Breath holding
!Dilated pupils
!Irregular respirations
Muscle tone intact

Vomiting, laryngospasm, cardiac arrest can happen.

Odom-Forren J. Drain’s Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders; 2013: 255)

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11
Q

What is the 3rd stage of anesthesia?

A

BEGINS with regular breathing pattern and ENDS with respiratory cessation

Absent protective reflexes
No eyelash response nor lid reflex
No spontaneous respiration
No response to surgical incision
Surgery occurs during this stage

Also referred to as surgical anesthesia.

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12
Q

What is the 4th stage of anesthesia?

A

Medullary depression
Depression of vital functions
Respiratory cessation
Cardiac / circulatory collapse

Also referred to as overdose (coding stage)

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13
Q

What is the order of anesthesia induction?

A
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14
Q

How does emergence from anesthesia occur?

A

!Reverse order of induction
Anesthesia agents titrated off
Influenced by
* Duration of anesthesia
* Use of other drugs
* Physical status of patient

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15
Q

What is the patient at risk for during the anesthesia stage of delirium?

A

Vomiting
Laryngospasm
Cardiac arrest

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16
Q

What is Glasgow Comma Scale?

A

GCS score range
15: Normal level of consciousness
14–15: Mild traumatic brain injury (TBI)
9–13: Moderate TBI
3–8: Severe TBI
3: Vegetative state or brain death

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17
Q

Where is the HIGH blood flow area for volatile & gaseous inhalation agents?

A

Kidney
Liver
Brain
Heart
Endocrine glands

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18
Q

Where is the MODERATE blood flow area for volatile & gaseous inhalation agents?

A

Muscle
Skin

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19
Q

Where is the POOR blood flow area for volatile & gaseous inhalation agents?

A

Fat
Bone marrow
Avascular tissue

The greater the fat the longer it takes to eliminate anesthesia.

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20
Q

Part of body with slowest elimination of volatile & gaseous inhalation agents

A

!Fat group - serves as area for anesthesia to linger. Thus more fat takes longer to eliminate anesthesia.

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21
Q

Why is SEVOFLURANE ( volatile & gaseous inhalation agent) good for induction and pediatrics?

A

!Pleasant, non irritating odor

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22
Q

What are safety profiles of SEVOFLURANE ( volatile & gaseous inhalation agent)?

A

Does not sensitize myocardium
No effect on hepatic blood flow
Safe for pts with seizure disorder
(d/t minimal increase ICP)

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23
Q

Volatile & gaseous inhalation agent

What are precautions for SEVOFLURANE?

A

!Potentiates neuromuscular blockade

Neuromuscolar blockers are either depolarizing or non-depolarizing.

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24
Q

Volatile & gaseous inhalation agent

How is SEVOFLURANE degraded?

A

!Degraded through exposure with soda lime*

*granular mixture of (Ca(OH)2), (NaOH) or (KOH), to absorb co2+moisture

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25
# Volatile & gaseous inhalation agent Why is HALOTHANE good for induction and pediatrics?
!Pleasant non-irritating odor Commonly used in pediatrics
26
# Volatile & gaseous inhalation agent What are **precautions** for HALOTHANE?
Can cause: **!Increased ICP** Myocardial depression Impaired AV node function Halothane hepatitis | Remember that Sevoflurane does not cause any of these.
27
# Volatile & gaseous inhalation agent How is HALOTHANE metabolized and excreted?
Metabolized in liver Excreted 80% lungs, 20% kidneys | Remember halothane hepatitis.
28
# Volatile & gaseous inhalation agent Why is ISOFLURANE only used as maintenance anesthesia?
Pungent, irritating odor
29
# Volatile & gaseous inhalation agent What is the **benefit** of administering ISOFLURANE?
Increases coronary blood flow
30
# Volatile & gaseous inhalation agent What are **precautions **for ISOFLURANE?
Causes vasodilation - post operative shivering Potentiates neuromuscular blockade | Neuromuscular blockers can either be depolarizing or non-depolarizing
31
# Volatile & gaseous inhalation agent How is ISOFLURANE metabolized and excreted?
Eliminated by exhalation Excreted by kidneys
32
# Volatile & gaseous inhalation agent Why is DESFLURANE used as maintenance anesthesia only?
Pungent, irritating odor | Same as isoflurane
33
# Volatile & gaseous inhalation agent What is the advantage of administering DESFLURANE?
!Rapid onset and offset due to extremely low solubility in blood | Good for rapid anesthesia induction and emergence like obese and elderly
34
# Volatile & gaseous inhalation agent What are precautions for DESFLURANE?
Causes vasodilation - post operative shivering Potentiates neuromuscular blockade (same as isoflurane) | Neuromuscular blockers can be depolarizing or non-depolarizing
35
# Volatile & gaseous inhalation agent How is DESFLURANE metabolized and excreted?
Eliminated through exhalation
36
# Anesthesia induction agents What are the different categories of anesthesia induction agents?
Sedative & hypnotic agents Dissociative agents Alpha2 agonists Benzodiazapines | Alpha2 adrenergic receptors bind to cathecolamine during body's stress
37
# Anesthesia induction agents What is an anesthesia induction agent?
Administered to induce anesthesia so anesthesia is initiated easily without residual effects.
38
# Anesthesia induction agents What kind of anesthesia induction agent is thiopental?
Ultra short acting CNS depressant that induces hypnosis and anesthesia, **but not analgesia** | Same as edomidate, does not provide analgesia
39
# Anesthesia induction agents What are the nursing precautions for anesthesia induction agent thiopental?
Can lower BP (use less dose if with cardiac issue) **Do not use if with sulfa allergy** Caution with liver patients | Garlic taste. Patient may experience hangover effect.
40
# Anesthesia induction agents What kind of anesthesia induction agent is methohexital sodium?
Barbiturate - acts as CNS depressant MOA - inhibit neurotransmitter GABA leading to calming/ sedative effect | Phenobarbital, a barbiturate (for seizure, treat anxiety or drowsiness)
41
# Anesthesia induction agents What are the nursing assessments for anesthesia induction agent methohexital?
Hiccup Cardiovascular depression Respiratory depression and apnea | Prepare for ventilation support, if needed
42
# Anesthesia induction agents What is kind of anesthesia induction agent is etomidate?
Hypnotic only, no analgesic non-barbiturate
43
# Anesthesia induction agents Why is anesthesia induction agent etomidate preferred for patients with cardiovascular disease?
Etomidate less likely to cause hypotension and with mimimal inotropic effects.
44
# Anesthesia induction agents What is common side effect for anesthesia induction agent etomidate?
Nausea and vomitting
45
# Anesthesia induction agents What is important to know about anesthesia induction agent etomidate?
Pain in IV site upon injection May cause temporary adrenal insufficiency* (Do not use in critically ill patients) | *Adrenal glands produce less cortisol and aldosterone.
46
# Anesthesia induction agents What is important to know about anesthesia induction agent propofol?
!Fat based !Contraindicated with patients with sensitivity to soybean oil, egg, lecithin, glycerol Administered with lidocaine on injection site d/t pain
47
# Anesthesia Agents/ Adjuncts/ Reversal What to watch out for about anesthesia induction agent propofol?
Propofol decreases blood pressure, cardiac output, and systemic vascular resistence. Elderly patients more susceptible. Pulse remains unchange due to sympatholytic or vagotonic effect. ## Footnote Odom-Forren J. Drain's Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders; 2013:267.
48
# Anesthesia induction agents What is kind of anesthesia induction agent is ketamine?
Dissociative anesthesia
49
# Anesthesia induction agents What is the side effect of anesthesia induction agent ketamine?
Hallucination Potential for abuse
50
# Anesthesia Agents/ Adjuncts/ Reversal How does anesthesia inducation agent ketamine affect the respiratory system?
Respiration function unimpaired but rapid iv injection can depress respiration temporarily Pharyngeal and laryngeal reflexes remain intact ## Footnote Odom-Forren J. Drain's Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders; 2013:274-276.
51
# Anesthesia Agents/ Adjuncts/ Reversal How does anesthesia inducation agent ketamine affect the neurological system?
Increased cerebral blood flow and inctracranial pressure ## Footnote Odom-Forren J. Drain's Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders; 2013:274-276.
52
# Anesthesia Agents/ Adjuncts/ Reversal How does anesthesia inducation agent ketamine affect the cardiovascular system?
Moderate accelaration of heart rate with temporary increase of pulse and blood pressure ## Footnote Odom-Forren J. Drain's Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders; 2013:274-276.
53
# Anesthesia induction agents How to reduce dissociative phenomena of anesthesia induction agent ketamine?
Request benzo for pre/post op to provide sedation Discuss possible vivid dreams/ hallucination to patient
54
What kind of anesthesia induction agent is clonidine?
alpha2 agonist provides sedation and analgesia without respiratory depression
55
What are the side effects of anesthesia induction agent clonidine?
Dry mouth Sedation Bradycardia Contact Dermatitis
56
What kind of anesthesia induction agent is dexmedetomidine?
alpha2 agonist provides sedation and analgesia without respiratory depression
57
What are the side effects of anesthesia induction agent is dexmedetomidine?
Bradycardia and hypotension because it potentiates effect of opioids, sedatives and hypnotics, anesthetics, and other vasoactive agents
58
What kind of anesthesia induction agent is midazolam?
Benzodiazapine - producing hypnotic effect, retrograde amnesia, anxiolysis and skeletal muscle relaxation
59
# Anesthesia Agents/ Adjuncts/ Reversal What are the side effects of anesthesia induction agent midazolam?
Decrease blood pressure **Increase** heart rate Decrease SVR | Caution with myocardial ischemia because it increases cardiac workload ## Footnote Odom-Forren J. Drain's Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders; 2013:269.
60
# Anesthesia Agents/ Adjuncts/ Reversal What is the reversal medication for anesthesia induction agent midazolam?
Oversedation - treated by Flumazenil 0.2mg IV over 15 seconds, repeated Q 1 minute, with maximum dose of 1mg
61
What are anesthesia adjuncts?
Administered to enhance anesthesia but not considered anesthetics. May serve to reduce anxiety, sedate patient, reduce oral/ respiratory secretions.
62
What is droperidol (anesthesia adjunct)?
Antiemetic
63
What is dexmedetomidine (anesthesia adjunct)?
Non-opioid IV anesthetic Controls stress, anxiety, and pain but no respiratory depression
64
What is the important characteristic of muscle relaxants?
!Do not cross blood brain barrier
65
Why are muscle relaxants needed?
To relax jaw and larynx during intubation To relax skeletal muscle for surgery
66
What prolongs the action of muscle relaxants?
Hypothermia
67
What is the sequence of PARALYSIS for muscle relaxants?
Fine motor -> Gross motor Eyes > Jaw > Hands > Limbs > Neck > Intercoastal Muscle > Diaphragm
68
What is the sequence of RECOVERY for muscle relaxants?
Reverse of paralysis Diaphragm > Intercoastal Muscle > Neck > Limbs > Hands > Jaw > Eyes
69
What is succinylcholine (depolarizing muscle relaxant)?
!Causes muscle to contract by binding to muscle cell receptor sites, competes with acetylcholine !Succinylcholine binds longer than acetylcholine Ultra short acting (5-10 min) Antinicotinic medication
70
What are the effects of succinylcholine (depolarizing muscle relaxant)?
!Fasciculations !Myalgia Can stimulate vagal nerve - bradycardia Mild histamine release - rashes on arms/ chest Increase ICP Increased release of k+ to extracellular fluid
71
# Anesthesia Agents/ Adjuncts/ Reversal During preoperative assessment, patient reports "I don't react well to anesthesia. The last time I had surgery, I had horrible muscle pain in my neck and back next day. It even hurts to blink my eyes and smile." The nurse suspects this discomfort was due to: a. surgical positioning b. ketamine c. succinylcholine d. rocuronium
Succinylcholine casues fasciculations or mini contractions as the muscle cell depolarizes after drug administration. These fasciculations frequently lead to muscle pain. ## Footnote Odom-Forren J. Drain's Perianesthesia Nursing: A Critical Care Approach. 6th ed. St. Louis, MO: Saunders; 2013:300.
72
What is "defasciculation"?
Administration of non depolarizing muscle relaxant prior to succinylcholine to prevent muscle twitch/ fasciculation.
73
29 y/o male admitted s/p fasciotomy for bilateral crush injuries of legs experiences partial laryngospasm when extubated. While preparing to intubate, anesthesia ask RN to administer succinylcholine 20mg IV. The RN shoud: 1. refuse to administer medication 3. request anesthesiologist to repeat dosage 3. dilute drug with 10cc NS before administration 4. titrate drug over 3 minutes
Refuse to administer medication because bilateral crush injuries can cause life threatening level of potassium release which is one of the contraindications of administering succinylcholine.
74
How is succinylcholine (depolarizing muscle relaxant) eliminated in the body?
Broken down by plasma cholinesterase aka pseudocholinesterase
75
Which part of the body produces pseudocholinesterase (depolarizing muscle relaxant)?
Produced by the liver Pseudocholinesterase level directly related to albumin level
76
Who can have pseudocholinesterase (depolarizing muscle relaxant) deficiency?
Inherited Advanced age, renal failure, malnutrition, hepatic disease
77
What is the effect of pseudocholinesterase deficiency (depolarizing muscle relaxant)?
!Prolonged paralysis that can lead to ventilation in PACU !Tincture of time
78
Patient had recent (past 2-4 days) neuromuscular injury. Why can't patient receive succinylcholine (depolarizing muscle relaxant)?
Can cause life threatening levels of K+ release (e.eg. major burns, multiple trauma, CVA, denervation of muscles, recent spinal cord injury - within 6 months)
79
Patient has chronic illness. Why can't patient receive succinylcholine (depolarizing muscle relaxant)?
Risk for hyperkalemia (e.g. prolonged immobilization, atrophy, critically ill)
80
Other medical conditions when patient can not be administered with succinylcholine (depolarizing muscle relaxant)?
Children with muscular dystrophies !History or family history of malignant hypothermia because succinylcholine can trigger MH
81
Patient developed respiratory failure and required intubation. Succinylcholine IV to be administered as part of rapid sequence intubation. Perianesthesia RN knows to have which drug ready to counteract fasciculations? 1. benzodiazaphines 2. non-depolarizing muscle relaxants 3. antihistamines 4. sustained released anticonvulsants
non-depolarizing muscle relaxants
82
What are non-depolarizing muscle relaxants?
Blocks acetylcholine from binding to muscle receptor sites. Thus muscle is unable to contract.
83
What medications enhance NDMR paralysis?
Aminoglycosides ! Calcium Channel Blockers Clindamycin Lithium Magnesium Tetracycline Volatile anesthetics
84
# Anesthesia Agents/ Adjuncts/ Reversal What physiological factors **enhance** NDMR paralysis?
Respiratory Acidosis **Hypothermia** Dehydration HYPERcapnia Hypokalemia Hyponatremia HYPERmagnesemia
85
What are considered NDMR **antagonists**?
**Caffeine** Hypocapnia Reversal agents HYPERkalemia Epinephrine HYPERnatremia Norepinephrine Respiratory Akalosis Theophylline
86
Name the long acting NDMRs?
!Tubocurarine !Doxacurium !Pancuronium !Pipecuronium
87
What are NDMR reversal agents?
!Anticholinesterase agents - inhibit breakdown of acetylcholine
88
What are common NDMR reversal agents?
!Sugammadex - reverses rocuronium and vecuronium Neostigmine - must be given with glycopyrrolate Edrophonium - must be given with atropine Pyridostigmine - given with glycopyrrolate
89
What to watch out for in administering Sugammadex (NDMR reversal agent)?
!Decreases serum concentration of estrogen and progestin derivatives
90
What is the mechanism of action for neostigmine (NDMR reversal agent)?
Neostigmine binds to acetylcholinesterase (anticholinesterase) thus increases the number of acetylcholine
91
What is the mechanism of action for Sugammadex (NDMR reversal agent)?
Sugammadex binds to NDMR, thus acetylcholine can occupy receptor sites
92
Why atropine or glycopyrrolate is administered with the NDMR reversal agent?
Neostigmine is cholinergic that cause muscarinic side effects such as bradycardia. Atropine and glycopyrrolate are anticholinergics that maintain stable heart rhythm.
93
Patient reversed with endrophonium and atropine. The reason for atropine administration is: 1. decrease likelihood of vomiting 2. promote acetylcholine release 3. enhance onset of nueromuscular reversal 4. minimize muscarinic stimulation
minimize muscarinic stimulation
94
Residual paralysis is a complication of what type of medication?
Non depolarizing muscle relaxants
95
What is residual paralysis (in NDMR)?
Reversal agent wears off before the breakdown of NDMR !common sign fish mouth breathing
96
What type of medication is glycopyrrolate?
Anticholinergic A quaternary amine used in anesthesia to decrease salivary and tracheal secretions, per National Library of Medicine
97
Why is glycopyrrolate given with neostigmine?
Neostigmine binds to acetylcholinesterase, thus increases the number of acetylcholine and reverses NDMR agent. Neostigmine is cholinergic with s/e bradycardia and bronchospasm. Glycopyrrolate is anticholinergic.
98
What are the side effects of anti cholinergucs?
dry mouth, blurred vision, increased heart rate, constipation, and urinary retention
99
What are the advantages of glycopyrrolate over atropine?
Works for a longer time and requires less amount of medication. Atropine can also cause delirium and confusion.
100
What is nitrous oxide?
Odorless, sweet smelling gas that is not potent to provide anesthesia
101
What is nursing concern for nitrous oxide?
High concentration can cause hypoxia. Therefor administer with O2.
102
How is nitrous oxide metabolized?
Diffusion, until it eventually equilibrates out

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