What are the Pre-Anesthesia Medications?
Anti-Anxiety / Amensia = Benzodiazepines like midazolam and Diazepam
Anacaids - Bicitra or H2 Blockers
Anti-emetics - Scopolomine patch - EVERY patient gets one to diminish post-op emesis which can lead to aspiration pneumonitis, ARDS and even death!!!
Why to trauma-surery patients tend to have high levels of recall from surgery?
bc they are limited in the general anesthesia that they can receive bc their BP is unstable
What are the IV induction agents?
Propofol, Ketamine, Etomidate, [Barbituates - thiopental]
Pros and Cons of Propofol
Pros - Rapid onset and short acting, flexibility of use, Anti-Emetic, Bronchodilation, Neuroprotection
Cons - Pain on injection, No analgesia, Hypotension from vasodilation, Egg/Soy allergy from Lecithin and requires sterile technique, respiratory depression
PIS - lactic acidosis due to cytopathic hypoxia with long term propofol sedation!!!
Pros and Cons of Etomidate
Pros - CV stability so used for cardiac patients/shockpts/hypovolemia, less respiratory depression/apnea and metabolized by ester hydrolysis
Cons - ADRENAL suppressoin which is bad for chronically ill pts who cant mount a stress response; Pain on injection; Myoclonus!!!
Pros and cons of Ketamine
Pros - Dissociative state, vasoconstrictor, Bronchodilator, less respiratory depression, analgesia
Cons - Psychotropic effects, HTN +/- Tachycardia (Caution with CAD/CVA pts), Direct cardiac depression in critically ill pts who can't increase sympathetic, Increased ICP and seizures (do NOT use in brian pts), Salivation, Emergence reaction
What is the most important element in analgesia for preventing long term pain?
Onset - Pre-emptive analgesia is key to preventing sensitization and long term pain
What are the IV analgesics used?
Fentanyl and Sufentanil
Remifentanil/Alfentanyl = fastest onset but last less time
Morphine/Dilodid = used on the floors a lot bc last 3 hours
Methadone = good baseline drug for people with chronic pain/IVDA but onset is longer and effects last longer
Pros and cons of opioids?
Pros - analgesia**, Minimal cardiac depression, reduces inhalational agents, versatile
Cons - respiratory depression (can get apneic fast and code), Bradycardia, skeletal muscle rigidity, N/V/Constipation
What is the depolarizing muscle relaxant? how does it work? What are the cautions in using it?
Succinylcholine = depolarizing NMBA
Mechanism: agonist at the NMJ on Nicotinic receptors and activates them and maintains depolarization
Will see fasciculations when giving it but good for Emergency surgery and rapid sequence induction
-AchE deficiency problem bc metabolized by plasma pseudocholinesterase and so dont wake up for 24 hours after giving it
- Bradycardia and Asystole (kids) so give with ATropine
- Malignant hyperthermia trigger
- Increased Intraocular pressure and ICP
What are the Non-depolarizing NMBA? Which one's good to use in Trauma? Which one causes tachycardia?
Rocuronium, Vecuronium, Cisatracurium, Pancuronium
Ciastracurium good in Trauma bc Hoffman Elimination of itself
Pancuronium causes tachycardia
What do you used for induction in pediatric pts?
Inhalational Induction - no IV
can give an anti-anxiolytic - oral/rectal/IM dart of benzo/ketamine
Induction with non-irritating volaties: Sevoflurane and N2O
What is MAC? What does it mean?
MAC = minimum alveolar concentration - concentration of inhaled anesthetic required to prevent movement in response to skin incision in 50% patients
Higher MAC = Less potent
ex. Iso Mac 1.1 which is more potent than Des Mac 6.6
What do all volatile anesthetics cause?
Pros and cons of Iso
Pros - cheap, and hemodynamic stability
Cons - Long-acting
Pros and Cons of Desflurane
Pros- rapid onset and elimination
Cons - pungent, expensive, tachycardia!!
Pros and Cons of SEvoflurane?
Pros - rapid and pleasant
cons - Emergence Delerium
Pros and Cons of Nitrous?
Pros - Second Gas Effect!!!! Non-pungent
Cons- NOT to be used in surgerys with air poclets or laparoscopics
What should you do for patients at increased risk for gastroparesis (ex. Diabetes)?
Give the premedication with Metoclopromide (Reglan)