Cumulative Final (Exam 1)

Question 1

Describe the three depths of sedation?

Answer 1

Question 2

What is the first inhaled anesthetic?

Answer 2

• Diethyl ether

Question 3

Describe the three depths of sedation?

Answer 3

Question 4

What is the first inhaled anesthetic?

Answer 4

• Diethyl ether

Question 5

What are the disadvantages of using ether?

Answer 5

• Flammable
• Prolonged induction and emergence
• Unpleasant odor
• High incidence of nausea and vomiting

Question 6

What is the anesthesia triad?

Answer 6

Amnesia, Analgesia, and Muscle Relaxation

Question 7

How is amnesia acheived?

Answer 7

Stimulating inhibitory transmission or Inhibiting stimulatory transmissions via GABA and ACh

Question 8

What is neuroplept anesthesia?

Answer 8

Using opioids, antipsychotics, and nitrous to induce anesthesia
Caused high incidence of awareness and dysphoria

Question 9

What is stage I of anesthesia and the 3 planes?

Answer 9

Beginning of induction of anesthesia to loss of conciousness
* 1st plane: no amnesia or analgesia
* 2nd plane: amnestic but only partially analgesic (versed/fentanyl)
* 3rd plane: complete analgesia and amnesia

Question 10

What is stage II of anesthesia?
What is this stage dangerous?

Answer 10

Loss of conciousness to onset of automatic breathing (ANS takes over)
* Eyelash reflex disappears
* Coughing, vomiting, and struggling may occur (risk of aspiration, bradycardia, and bronchospasm)
* Need to get through this stage as quickly as possible

Question 11

What is stage 3 of anestheisa and the 4 planes?
What plane is desired prior to administering NMB?

Answer 11

Onset of automatic breathing to respiratory paralysis (surgical plane)
* 1st plane: automatic respiration to cessation of eyeball movements
* 2nd plane: cessation of eyeball movements to beginning of intercostal muscle paralysis; secretion of tears increases
* 3rd plane: beginning to completion of intercostal muscle paralysis; pupils dilate; desired plane prior to muscle paralysis (think 3 and 3)
* 4th plane: comple intercostal muscle paralysis to diphragmatic paralysis (apnea)

Question 12

What is stage 4 of anesthesia?

Answer 12

Apnea until death… not desirable obviously

Question 13

What is a partial and inverse agonist?
Examples of inverse agonists?

Answer 13

• Partial: has less effect than full agonist even in higher doses
• Inverse: binds at active site but causes an opposing effect from the agonist (propanolol, metoprolol, cetirizine, loratidine, prazosin, naloxone)

Question 14

What is tachyphylaxis?
What 2 drugs undergo this?
What condition?

Answer 14

Tachyphylaxis: Rapid tolerance to a drug produce diminishing effects with each administration
- Albuterol (receptors downregulate due to repetition)
- Ephedrine (depletion of stored presynaptic catecholamines with each dose)
- Pheochromocytoma (decreased β receptors in response to catecholamines)

Question 15

What drugs bind to intracellular receptors?

Answer 15

• Insulin
• Steroids
• Milrinone

Question 16

What is the vessel rich group?

Answer 16

Bolused drugs first distrubute to tissues that receive the bulk of arterial blood flow: the brain, heart, kidneys, and liver.

Question 17

What is meant by a high and low V_D?

Answer 17

High: drug distributes out of blood to tissue quickly - (lipid soluble drugs)
Low: drug stays within the cardiovascular system - (water soluble drugs)

Question 18

What proteins do acidic and basic drugs bind to?

Answer 18

Acidic = Albumin
Basic = ⍺1-acid glycoprotein

Question 19

If a drugs normal free fraction is 2% and their albumin is dropped by half, what is the new free fraction?
What does this mean?

Answer 19

• 4%
• This means with the same dose, the patient may have double the effect which usually comes with undesirable effects

Question 20

What are the Phase I reactions?
What is their purpose?

Answer 20

• Oxidation, Reduction, and Hydrolysis
• Increases drug polarity to make them more water soluble in preparation for elimination

Question 21

What is the phase II reaction?
What does it do?

Answer 21

• Conjugation
• Links covalently with a polar molecule to become more water soluble

Question 22

What is flow limited clearance?

Answer 22

• Rate of clearance is proportional to drug concentration
• More hepatic flow = more clearance

Question 23

What is capacity limited clearance?

Answer 23

• Liver metabolism is the limiting factor for drug clearance
• Only a certain amount can be cleared, regardless of changes in flow

Question 24

If a drug has a 1/2 time of 10 minutes, what fraction of drug remains after 40 mins?

Answer 24

1/16 th

Question 25

What is context-sensitive half time? Why does this matter?

Answer 25

* The half time after a continuous infusion (assuming constant concentration) * Because many anesthetic drugs are lipid solubule and will accumulate in the tissues, meaning the longer the infusion is run, the longer the effects are seen.

Question 26

What is the pneumonic to remember if a drug is ionized or not? What number are nonionized drugs?

Answer 26

* Weak **A**cids: pK **A**fter pH (pH - pK) * Weak **B**ases: pK **B**efore pH (pK - pH) * Negative numbers: “nicely negative numbers are nonionized”

Question 27

What are some drugs we give that are weak acids and weak bases?

Answer 27

Weak acids: barbituates Weak bases: local anesthetics and opiods

Question 28

What is ion trapping?

Answer 28

When a non-ionized drug becomes ionized in a part of the body and accumulates. Ex: Mother with normal pH and baby with acidic pH → local anesthetic/opiod becomes ionized in baby's body → ionized drug can't cross membranes and accumulates, causing a increased effect on the baby

Question 29

How do you calculate therapeutic index?

Answer 29

LD₅₀ ÷ ED₅₀

Question 30

What is the enatiomer of cisatracurium?

Answer 30

Atracurium

Question 31

What drugs can decrease BIS?

Answer 31

Synergistic anesthetics like hypnotics, volatiles, NMB, opiods

Question 32

What range of BIS prevents recall?

Answer 32

40-60

Question 33

What should the EMG be on a paralyzed patient?

Answer 33

0

Question 34

What is the supression ratio? What should it be?

Answer 34

- Measures how often the patient's BIS hit 0 - Should never have a number here or your anestheic is way too deep

Question 35

How do sympathomimetics and sympatholytics affect the BIS?

Answer 35

- Sympathomimetics: may have a ↑ BIS due to ↑ catecholamines, but are still amnestic (ketamine) - Sympatholytics: BIS may be lower due to decreased SNS activity, despite having actually being more aware

Question 36

What are the 5 effects of benzodiazepines?

Answer 36

1. Anxiolysis 2. Sedation 3. Anterograde amnesia (lasts longer than sedation) 4. Anticonvulsant 5. Spinal cord mediated muscle relaxation

Question 37

What is the MOA of benzodiazepines?

Answer 37

- Binds to GABA A_⍺/Ɣ subunits increasing Cl- entry into the cell causing hyperpolarization - Potentiates the GABA site

Question 38

What are benzos different effects at ⍺1 and ⍺2 subunits?

Answer 38

- ⍺1: sedative, amnestic, anticonvulsant (most abundant) - ⍺2: anxiolytic, skeletal muscle

Question 39

What are the pulmonary effects of midazolam?

Answer 39

- Dose dependent decrease in ventilation - Depresses swallowing reflex and upper airway activity = aspiration risk

Question 40

What are the CV effects of midazolam?

Answer 40

↑ HR, ↓BP, ↓SVR CO unchanged

Question 41

What is the preop dosing for midazolam for children and adults?

Answer 41

Children: 0.25-0.5mg/kg orally Adults: 1-5mg IV

Question 42

What is the induction dose for midazolam?

Answer 42

0.1-0.2 mg/kg over 30 seconds

Question 43

Why do valium and lorazepam burn on injection?

Answer 43

The solvent propylene glycol

Question 44

What are the CNS effects of diazepam?

Answer 44

- ↓CBF/CMRO2 - Potent anticonvulsant - Can produce an isoelectric EEG

Question 45

What is the induction dose for valium?

Answer 45

0.5-1.0 mg/kg IV

Question 46

What drugs do flumazenil reverse?

Answer 46

Any drug that agonizes the GABA receptor - including psych and anti-seizure meds

Question 47

What is the dosing for Romazicon?

Answer 47

0.2 mg IV then 0.1 mg q 1 min, up to 1 mg total

Question 48

What 3 things does histamine release cause?

Answer 48

1. Contractions of airway smooth muscle 2. Gastric acid secretion 3. Release of NT in the CNS (ACh, norepinephrine, and serotonin)

Question 49

What 4 drugs mentioned in lecture induce histamine release as a side effect?

Answer 49

- Morphine - Mivacurium (Mivacron) - Protamine - Atracurium (Tracrium)

Question 50

What other receptors can histmaine activate at H1 and H2?

Answer 50

H1 - muscarinc, cholinergic, 5HT3, and ⍺-adrenergic H2 - 5HT3 and β1

Question 51

What are the effects of histamine on the H1 receptor?

Answer 51

Inflammatory pain, hyperalgesia, and allergic rhino-conjunctivitis symptoms

Question 52

What are the effects of histamine on the H2 receptor?

Answer 52

* ↑ cAMP (β1-like stimulation) * ↑ gastric acid and volume

Question 53

What are the systemic effects from both H1 and H2 stimulation?

Answer 53

- Hypotension from NO release - Capillary permeability - Flushing - Prostacyclin release

Question 54

Where are H1 receptors found?

Answer 54

* Vestibular system * Airway smooth muscle - Cardiac enodthelial cells

Question 55

What are the 2 H1 antagonist given pre-op?

Answer 55

- Diphenhydramine (Benadryl) - Promethazine (Phenergan)

Question 56

Why are second generation H1 antagonists sometimes preferred? Examples?

Answer 56

- Do not cross the BBB, less sedation - Cetirizine (Zyrtec) - Loratadine (Claritin)

Question 57

Why is there a black box warning for promethazine (phenergan)?

Answer 57

- Fatal bronchospasms in children less than 2 - Causes tissue ischemia if infiltrated

Question 58

What is the primary use for H2 antagonists

Answer 58

- Used for duodenal ulcer disease and GERD - Decreases hypersecretion of gastric fluid - ↓ Gastric volume, ↑ pH

Question 59

What are the 3 examples of H2 receptor antagonists?

Answer 59

Cimetidine (Tagamet) Rantidine (Zantac) Famotidine (Pepcid)

Question 60

Which H2 antagonist would you avoid in patients with bone disorders?

Answer 60

Famotidine - interferes with phosphate absorption causing hypophosphatemia

Question 61

What is the MOA of PPIs?

Answer 61

Inhibits movement of protons in gastric parietal cells - only works on currently active pumps

Question 62

What are the time considerations for PPI's?

Answer 62

Can take up to 5 days to have onset Not much effectiveness in same day cases

Question 63

What is the naming convention for PPIs?

Answer 63

-prazole

Question 64

What are PPIs most effective for?

Answer 64

Decreasing gastric volume and controlling acidity

Question 65

Which PPI can begin to start working as soon as 1 hour?

Answer 65

Pantoprazole, although probably not effective enough to prevent aspiration prior to surgery

Question 66

What type of antacid would we never give pre-op? Why?

Answer 66

Particulate (aluminum/magnesium based) Would be worse if aspirated

Question 67

Which patients do we always give sodium citrate (Bicitra)?

Answer 67

C sections

Question 68

Why do we give Bicitra to surgical patients?

Answer 68

It works immediately to neutralize stomach acid to protect against aspiration pneumonitis

Question 69

What is the MOA for dopamine blockers?

Answer 69

Stimulate gastric motility by increasing lower esophageal sphincter tone and relaxing pylorus and duodenum. | Dopamine inhibts muscle movement

Question 70

What is the naming convention for 5HT3 antagonists?

Answer 70

-setron

Question 71

What is the most important side effect to know about ondansetron (Zofran)?

Answer 71

Causes slight QT prolongation

Question 72

What are the preposed MOA of anti-emetic effects of corticosteroids?

Answer 72

Controls endorphin release and produces anti-inflammatory effects (less pain, less opioids)

Question 73

When should you administer decadron to prevent PONV? Airway edema?

Answer 73

* PONV: 2 hours before extubating (takes 2 hours for onset) * Airway: immediately after intubation

Question 74

Why is scopolamine the anticholinergic of choice for prevention of PONV?

Answer 74

Produces more desirable effects than the others: