Exam 2: 24 Feb Multi-Modal and GA

Question 1

What is multi-modal anesthesia?

Answer 1

An anesthesia approach that combines multiple techniques to enhance pain management and reduce opioid use.

It includes aspects like preoperative care, fluid loading, short-acting agents, opioid-sparing agents, temperature management, and neuromuscular monitoring.

Question 2

What is the significance of the $630.5 billion statistic in the context of pain management?

Answer 2

It represents the economic impact of pain in the US, highlighting the need for effective pain management strategies.

This statistic is from 2012 and reflects the growing opioid overdose crisis.

Question 3

What are some non-opioid alternatives for pain management mentioned by Dr. Castillo?

Answer 3

• Massage
• Physical Therapy (PT)
• Occupational Therapy (OT)
• Behavioral interventions
• Non-opioid anesthesia

Other alternatives include yoga and Tai Chi.

Question 4

Define opioid-free anesthesia.

Answer 4

An anesthetic technique that provides anesthesia and post-op pain relief without the use of opioids.

It involves using medications that block surgical and post-surgical pain.

Question 5

What is the definition of pain according to the International Association for the Study of Pain?

Answer 5

An unpleasant sensory and emotional experience.

Pain can be classified as acute or chronic.

Question 6

List the major components of pain pathways discussed in the content.

Answer 6

• Stimulation
• Sensation transduction
• Transmission
• Perception
• Modulation
• Response

These components are critical for understanding how pain is processed in the body.

Question 7

What medication is used for post-op nausea and vomiting?

Answer 7

Ondansetron (Zofran)

It is often combined with Decadron for enhanced anti-nausea effects.

Question 8

What role does Gabapentin play in pain management?

Answer 8

It acts as a structural analog of GABA, enhancing descending inhibition and reducing pain perception.

Commonly used for chronic pain syndromes and given pre-operatively.

Question 9

What are the recommended dosages for Acetaminophen in pre-op settings?

Answer 9

1000 mg PO

Dosage can vary, but it is typically administered before surgery.

Question 10

True or False: Magnesium can promote hypotension.

Answer 10

True

It is used for blood pressure control but must be monitored closely.

Question 11

What is the maximum daily dosage for Ketorolac?

Answer 11

3200 mg per day

This is for IV administration over specific intervals.

Question 12

What are the two types of NSAIDs mentioned?

Answer 12

• Non-specific NSAIDs (e.g., Ibuprofen, Naproxen)
• Cox-2 selective inhibitors (e.g., Celebrex)

Each type has different mechanisms and benefits.

Question 13

Fill in the blank: The use of _______ is emphasized for opioid-sparing techniques in anesthesia.

Answer 13

[opioid-sparing agents]

Question 14

What are the benefits of using Cox-2 inhibitors?

Answer 14

• Reduced gastric protection
• Less impact on hemostasis

These benefits make them preferable in specific situations.

Question 15

What is a significant risk of using Lidocaine?

Answer 15

Toxicity if not monitored properly.

It is important for peripheral nerve blocks and regional anesthesia.

Question 16

What is Decadron used for in the context of anesthesia?

Answer 16

Post-op nausea and vomiting, and pain management.

It may also affect blood sugar levels in diabetic patients.

Question 17

How is Methadone viewed in the context of pain management?

Answer 17

As a potential non-opioid alternative with ongoing studies on its efficacy.

Its legalization varies by state.

Question 18

What should be monitored when administering Magnesium?

Answer 18

Blood pressure

Magnesium can cause hypotension, requiring careful observation.

Question 19

What is the initial dose of Gabapentin given to the patient preoperatively?

Answer 19

200 milligrams PO

Given with a sip of water prior to surgery, typically 30 minutes to an hour before.

Question 20

What additional medications are commonly given in a preoperative pain management cocktail?

Answer 20

• Brex 100 milligrams PO
• Tylenol 1000 milligrams PO
• Pepsi 20 milligrams IV
• Zofran 4 milligrams IV
• Versa 1 milligram IV
• Decadron 4 to 10 milligrams IV

Decadron is used for pain management and to reduce postoperative nausea and vomiting.

Question 21

What are some potential side effects of Gabapentin?

Answer 21

• Ataxia
• Vertigo
• Gastrointestinal disturbances
• Withdrawal symptoms
• Seizures
• Weight gain

These side effects can vary in severity and occurrence.

Question 22

What was a limitation of the 2017 meta-analysis regarding Gabapentin?

Answer 22

It only included 10 randomized controlled trials with 827 patients

Typically, meta-analyses involve thousands of patients for more robust conclusions.

Question 23

What is the typical protocol dose of Gabapentin for elderly patients in Naples?

Answer 23

200 milligrams

This is based on the established protocol for pain management.

Question 24

What is the primary purpose of NSAIDs?

Answer 24

Analgesia, anti-inflammatory effects, and fever reduction

NSAIDs can decrease activation of peripheral nociceptors and provide preemptive analgesia.

Question 25

How do NSAIDs affect gastric protection?

Answer 25

They can inhibit gastric protection if they affect the COX-1 pathway ## Footnote This can lead to ulcerations and gastrointestinal issues.

Question 26

What distinguishes COX-1 from COX-2 inhibitors?

Answer 26

* COX-1 is ubiquitous and responsible for gastric protection * COX-2 is specific for inflammation and fever ## Footnote COX-2 inhibitors are preferred to avoid gastrointestinal side effects.

Question 27

What are some examples of non-specific NSAIDs?

Answer 27

* Ibuprofen * Naproxen * Aspirin * Acetaminophen ## Footnote These are commonly used but may lead to more side effects compared to COX-2 selective NSAIDs.

Question 28

What is the peak action time for Celebrex?

Answer 28

3 hours ## Footnote The typical dosage ranges from 200 to 400 milligrams.

Question 29

What is the maximum daily dosage of acetaminophen recommended?

Answer 29

3000 to 4000 milligrams ## Footnote Some sources suggest different maximums, hence the range.

Question 30

What is the mechanism of action of acetaminophen?

Answer 30

Inhibits prostaglandin synthesis by inhibiting both COX-1 and COX-2 ## Footnote It has analgesic and antipyretic properties but lacks significant anti-inflammatory effects.

Question 31

What is a relative contraindication for using Ketorolac in elderly patients?

Answer 31

Age over 65 years ## Footnote While age can be a concern, it is not an absolute contraindication if the patient is otherwise healthy.

Question 32

What can happen with the excessive use of non-specific NSAIDs?

Answer 32

Gastrointestinal ulceration and renal impairment ## Footnote This is due to their action on COX-1 and COX-2 pathways.

Question 33

What is the peak action time for Ketorolac?

Answer 33

45 to 60 minutes ## Footnote This timing is advantageous for pain management during emergence.

Question 34

What are some contraindications for using Ketorolac?

Answer 34

* Severe renal impairment * Active bleeding * History of peptic ulcer disease * Allergies to NSAIDs ## Footnote These factors must be carefully considered before administration.

Question 35

What are the effects of ibuprofen as a non-specific NSAID?

Answer 35

* Anti-inflammatory * Analgesic * Antipyretic ## Footnote It inhibits both COX-1 and COX-2 pathways.

Question 36

What are the main properties of ibuprofen?

Answer 36

Anti-inflammatory, analgesic, antipyretic ## Footnote Ibuprofen inhibits both COX-1 and COX-2 via the cyclooxygenase pathway.

Question 37

What is an absolute contraindication for ibuprofen?

Answer 37

Allergy to NSAIDs ## Footnote Common in patients with systemic lupus erythematosus (SLE) who may be allergic to aspirin.

Question 38

What is the maximum daily dose of ibuprofen?

Answer 38

3200 mg ## Footnote This is the maximum limit within a 24-hour period.

Question 39

What is the typical dosing schedule for ibuprofen IV?

Answer 39

200 to 800 mg IV over 30 minutes every six hours PRN ## Footnote PRN stands for 'as needed'.

Question 40

When should ibuprofen be administered preoperatively?

Answer 40

Start in pre-op for analgesic effects ## Footnote Especially important for pain management during recovery.

Question 41

What is the peak effect time for ibuprofen?

Answer 41

1 to 2 hours ## Footnote This is when the drug reaches its maximum effect.

Question 42

What is the mechanism of action for lidocaine?

Answer 42

Sodium channel blocker ## Footnote Lidocaine is used as both a local anesthetic and an antiarrhythmic agent.

Question 43

What are the available concentrations of lidocaine for peripheral nerve blocks?

Answer 43

1% and 2% ## Footnote 1% lidocaine contains 10 mg/ml, while 2% contains 20 mg/ml.

Question 44

What is the typical dosing for lidocaine IV?

Answer 44

1 to 2 mg/kg IV bolus over 2 to 4 minutes, then 1 to 2 mg/kg/hour drip ## Footnote This is important to prevent lidocaine toxicity.

Question 45

What are the side effects of lidocaine toxicity?

Answer 45

Circumoral numbness, tinnitus, seizures, cardiac depression ## Footnote Monitoring is crucial to prevent severe adverse effects.

Question 46

What role does magnesium play in pain management?

Answer 46

NMDA receptor antagonist, potentiates opioids ## Footnote Magnesium also regulates calcium access into cells.

Question 47

What is the contraindication for magnesium administration?

Answer 47

Myasthenia gravis and renal failure ## Footnote Magnesium can cause muscle weakness, which is risky for these patients.

Question 48

What is the typical dosing for magnesium IV?

Answer 48

15 mg/kg IV bolus, then 8 mg/kg/hour drip ## Footnote Adjustments may be needed based on patient response.

Question 49

What is the mechanism of action for ondansetron (Zofran)?

Answer 49

5-HT3 receptor antagonist ## Footnote It is primarily used for nausea and vomiting but does not have direct analgesic properties.

Question 50

What are common side effects of ondansetron?

Answer 50

Headaches, constipation, QT prolongation ## Footnote QT prolongation is more likely with rapid administration.

Question 51

What is the typical dosing for ondansetron IV?

Answer 51

4 to 8 mg IV ## Footnote Pediatric dosing is 0.1 mg/kg IV.

Question 52

What is the role of dexamethasone (Decadron) in nausea management?

Answer 52

Anti-inflammatory and enhances the effectiveness of Zofran ## Footnote It stabilizes cellular membranes and inhibits phospholipids and cytokines.

Question 53

What is the dosing for dexamethasone?

Answer 53

4 mg IV ## Footnote Often given as part of multimodal protocols for nausea prevention.

Question 54

What is the significance of using dexamethasone with peripheral nerve blocks?

Answer 54

Extends the duration of local anesthetics ## Footnote Studies show it enhances the effectiveness of nerve blocks.

Question 55

What is the effect of Decadron when used as an adjunct for a peripheral nerve block?

Answer 55

It extends the life of the block, providing pain relief for 24 to 48 hours. ## Footnote Decadron is often used to enhance the efficacy of local anesthetics in peripheral nerve blocks.

Question 56

How does the administration of Decadron differ when given IV versus mixed with local anesthetic?

Answer 56

Both methods appear to work the same, but the IV method may prolong the block effect without mixing it directly with the anesthetic. ## Footnote Literature supports both administration methods.

Question 57

When is the ideal timing for administering Decadron prior to surgery?

Answer 57

It is usually recommended to give it prior to incision, but it can be administered in pre-op to ensure efficacy. ## Footnote The onset can be delayed by two hours.

Question 58

What are the potential adverse effects of Decadron in diabetic patients?

Answer 58

There are no adverse effects from a single dose with diabetics, according to meta-analyses. ## Footnote Studies show stability in blood sugar levels with single doses.

Question 59

What is the primary benefit of using Decadron in post-anesthesia care?

Answer 59

It helps in controlling nausea and vomiting and improves pain management. ## Footnote Decadron is effective in multimodal analgesia.

Question 60

What potential side effect should be monitored when administering Decadron?

Answer 60

Perineal burning or itching, especially in female patients. ## Footnote Slow administration is advised to minimize this effect.

Question 61

What is the impact of enhanced recovery after surgery (ERAS) protocols on hospital stay and complications?

Answer 61

They can reduce hospital stay and complications by 30 to 50%. ## Footnote ERAS focuses on minimizing opioid use and enhancing recovery.

Question 62

What are the three pillars of ERAS protocols mentioned?

Answer 62

* Avoiding short-acting IV sedatives * Using alternatives to opiates (e.g., acetaminophen, NSAIDs) * Administering dexamethasone and gabapentin ## Footnote These components aim to enhance recovery and reduce opioid requirements.

Question 63

What is methadone's current status in ERAS protocols?

Answer 63

There are mixed studies on its efficacy, and it is not widely used yet. ## Footnote Its potential legalization in various states may change its status.

Question 64

What is the elimination half-time of dexmedetomidine compared to clonidine?

Answer 64

Dexmedetomidine has a half-time of 2 to 3 hours, while clonidine is 6 to 10 hours. ## Footnote This makes dexmedetomidine potentially safer due to its shorter action.

Question 65

What is a key consideration when using dexmedetomidine for sedation?

Answer 65

It can depress ventilation, necessitating a secured airway during use. ## Footnote Monitoring is crucial, especially at higher doses.

Question 66

What is the recommended bolus dose of dexmedetomidine?

Answer 66

0.5 to 1 mcg/kg over 10 minutes. ## Footnote This dosing is critical in avoiding adverse effects.

Question 67

What should be considered when asking patients about their smoking habits?

Answer 67

Inquire specifically about cannabis use in addition to traditional tobacco products. ## Footnote Cannabis use is increasingly common and should be addressed in pre-op assessments.

Question 68

What does the Society for Opioid Free Anesthesia focus on?

Answer 68

They promote opioid-free anesthesia techniques. ## Footnote Their presentations often cover alternative pain management strategies.

Question 69

How much lidocaine is administered to a 60 kg patient in the example given?

Answer 69

60 mg initially, followed by a subsequent infusion calculated based on the patient's weight and time. ## Footnote The total dosage calculation is essential for patient safety.

Question 70

What is the significance of dexmedetomidine in total IV anesthesia?

Answer 70

It decreases the perioperative requirements for inhaled anesthetics by 90%. ## Footnote This highlights its effectiveness in reducing overall anesthetic use.

Question 71

What is the recommended dosing for dexmedetomidine when used in epidural anesthesia?

Answer 71

2 mcg/kg for epidural compared to 3 or 5 mcg for intrathecal administration. ## Footnote This difference accounts for the need for diffusion across the dura.