exam 2 chap. 1-11 Flashcards
1
Q
Tool used to assess for sleep apnea STOP BANG, what does it stand for?
A
The acronym STOP stands for Snoring, Tired (daytime sleepiness), Observed apnea, and high Pressure; and the acronym BANG stands for BMI 35 or greater, Age 50 years or older, Neck circumference 40 cm (17 inches) or larger, and male Gender.
2
Q
What neurotransmitters are involved in wakefulness?
A
acetylcholine, dopamine, norepinephrine, histamine, and 5-hydroxytryptamine (serotonin)
3
Q
Which neuronal pathway is responsible for wakefulness?
A
ascending reticular activating system (ARAS)
4
Q
How is sleep maintained?
A
inhibition of the ARAS via a hypothalamic nucleus known as the ventrolateral preoptic (VLPO)
5
Q
What neurotransmitters are involved in sleep?
A
γ-aminobutyric acid (GABA) and galanin
also adenosine
6
Q
How does adenosine promote sleep?
A
inhibiting cholinergic ARAS neurons and activating VLPO neurons
7
Q
What is the hallmark of OSA?
A
sleep-induced hypoxia and arousal-relieved upper airway obstruction
8
Q
conditions associated with increased prevalence of OSA include?
A
hypertension, CAD, MI, CHF, afib, stroke, type 2 DM, nonalcoholic steatohepatitis (NASH), polycystic ovarian syndrome, Graves’s disease, hypothyroidism, and acromegaly
9
Q
PREdisposing factors for OSA include?
A
o genetic inheritance o non-Caucasian race o upper airway narrowing o obesity o male gender o menopause o use of sedative drugs and alcohol o cigarette smoking
10
Q
Tell me about obesity and OSA?
A
Obesity is a risk factor for OSA in all age groups.
A 10% increase in body weight is associated with a 6-fold increase in the odds of having OSA and a 32% increase in the apnea-hypopnea index
A 10% weight loss is associated with a 26% decrease in the apnea-hypopnea index
11
Q
What is the most reliable stimulator of arousal? (talking about respiratory-related arousal response being stimulated by)
A
the work of breathing
hypercapnia, hypoxia, and upper airway obstruction also
12
Q
s/s of OSA?
A
daytime sleepiness, fatigue, insomnia, snoring, subjective nocturnal respiratory disturbance, observed apnea
13
Q
Children with an acute URI are more likely to have?
A
Hypoxemia and laryngospasm
14
Q
Factors that put children at an increased risk for respiratory complications?
A
o History of copious secretions o Prematurity o Parental smoking o Nasal congestion o Reactive airway disease o Endotracheal intubation o Airway surgery o Clear systemic signs of infection (fever, purulent drainage, productive cough, and rhonchi) are at CONSIDERABLE risk for adverse events in the peri-op period
15
Q
Is asthma a reversible or irreversible airflow obstruction?
A
REVERSIBLE
16
Q
Asthma is REVERSIBLE airflow obstruction characterized by? (3)
A
o Bronchial hyperreactivity
o Bronchoconstriction
o Chronic airway inflammation
17
Q
s/s of asthma?
A
Characterized by acute exacerbations mixed with periods of no symptoms
Wheezing, productive or nonproductive cough, dyspnea, chest tightness that may lead to air hunger, and eosinophilia
18
Q
diagnosis of asthma?
A
FEV1, FEV1/FVC ratio, and FEF25-75% all reduced but improve with bronchodilators
19
Q
how does the flow volume loop look for someone with asthma?
A
Downward scooping of the expiratory limb
20
Q
Flow-volume loops where the inspiratory or expiratory portion is flat suggest wheezing that is caused by what?
A
upper airway obstruction
foreign body, tracheal stenosis, or mediastinal tumor
21
Q
If asthma is suspected based on s/s what test will provide supporting evidence?
A
bronchodilator responsiveness
22
Q
what do ABGs look like with mild asthma?
A
normal PaO2 and PaCO2
23
Q
what is the most common ABG finding in asthma ?
A
Hypocarbia and respiratory alkalosis
24
Q
what does it mean when the PaCO2 is increased in asthma?
A
when the FEV1 is <25% of the predicted value
This usually indicates skeletal muscle fatigue and impending respiratory failure → intubate!
25
name some short acting bronchodilators used for asthma relief?
albuterol, levalbuterol which are both B2- agonists (stimulates B2 receptors in tracheobronchial tree)
26
name some long acting bronchodilators that are B2 agonists?
Arformoterol (Brovana), Formoterol, Salmeterol
27
name some inhaled corticosteroids for asthma?
Beclomethasone, Budenoside, Ciclesonide, Flunisolide, Fluticasone (Flovent), Mometasone, Triamcinolone
28
long acting bronchodilators should always be used with what other drug and why?
Using long-acting bronchodilators ALONE can cause airway inflammation and increase asthma exacerbations.
ALWAYS use with inhaled corticosteroid
29
Name some combined inhaled corticosteroids + long acting bronchodilators?
Budesonide + Formoterol (Symbicort), Fluticasone + Salmeterol (Advair)
30
Cromolyn is?
mast cell stabilizer
31
name some leukotrine modifiers?
Montelukast (Singulair), Zafirlukast (Accolate), Zileuton (Zyflo)
32
how does theophylline / aminophylline work?
increases cAMP by inhibiting phosphodiesterase
- Blocks adenosine receptors
- Releases endogenous catecholamines
33
what opioid do you avoid if someone has asthma?
morphine due to histamine release
34
what is status asthmatics?
life threatening bronchospasm that persists despite treatment
35
during an asthma attack of any kind, hypercarbia requires what?
tracheal intubation and mechanical ventilation
36
how should the ventilator be adjusted for asthma?
prolonged expiratory phase to allow for complete exhalation.
37
what reductions in PFTs are considered a risk factor for perioperative respiratory complications?
reduction in FEV1 or FVC to less than 70% of predicted.
FEV1:FVC ration that is less than 65% of predicted.
38
FEV1 means?
forced expiratory volume in 1 second.
volume of air that can be exhaled in 1 sec.
Normal is greater than 80% of predicted value.
39
FVC means?
forced vital capacity which is the volume of air that can be exhaled after a deep inhalation.
normal for males is 4.8L and females is 3.7 L
40
reason for bronchospasm during anesthesia that is not asthma?
light on gas, check your MAC
41
S/S of bronchospasm intra- op?
* High peak airway pressure
* Upsloping of ETCO2 waveform
* Wheezing
* Desaturation
42
differential diagnosis of intra operative bronchospasm and wheezing includes?
```
o Kinking
o Secretions
o overinflation of ETT cuff
o light anesthesia
o endobronchial intubation
o aspiration
o pulmonary edema
o PE
o Pneumo
o acute asthma attack
```
43
treatment of bronchospasm?
Deepening anesthesia with either volatile agents or IV injections of propofol and administration of a rapid-acting β2-agonist (Albuterol)
If bronchospasm continues, other drugs (IV corticosteroids, Epi, Mag) may be necessary
44
Restrictive lung dz and the choice of drugs for induction or maintenance?
does not influence
45
restrictive lung dz is characterized by?
decrease in ALL lung volumes, especially Total Lung Capacity (TLC)
46
what drugs/ techniques should be avoided with patients who have restrictive lung dz?
drugs with prolonged resp. depression into the post op. period.
regional above T10
47
what does restrictive lung dz look like on a flow volume loop?
small ice cream cone
48
what does obstructive lung dz look like on a flow volume loop?
took a bite out of my ice cream cone (baby carriage)
49
example of fixed lesion dz?
tracheal stenosis
50
Progressive loss of alveolar tissue and progressive airflow obstruction that is NOT reversible describes?
COPD
51
Why might emergence be prolonged in someone with COPD?
D/T air trapping
52
why be cautious with the use of nitrous and a patient with COPD?
may cause enlargement or rupture of bullae leading to tension pneumo
53
tidal volumes for COPD patient?
low, 6-8mL/kg
54
peak pressures for COPD patient?
less than 30 cm H2O
55
I:E ratio for COPD and why?
you want to allow for adequate time for expiration to avoid air trapping. 1:3 ratio
56
What do you want the RR at for a COPD patient?
lower RR to give more time in the expiratory phase
57
who is at risk for bronchospasm?
COPD patients
58
definitive diagnosis for COPD?
SPIROMETRY
59
tell me about pulmonary fibrosis?
S/S?
What develops because you have pulmonary fibrosis?
• Interstitial lung disease is characterized by changes in the intrinsic properties of the lungs and is most often caused by pulmonary fibrosis that produces chronic restrictive form of lung disease.
Pulmonary hypertension and cor pulmonale develop as progressive pulmonary fibrosis results in the loss of pulmonary vasculature.
Dyspnea is prominent, and breathing is rapid and shallow.
60
what is sarcoidosis?
| what medication is given for sarcoidosis and why?
• Inflammatory disease characterized by growth of benign inflammatory masses. Many present with no symptoms and disease is identified by abnormal findings on chest x-ray. Some may have dyspnea and cough. Corticosteroids are administered to suppress the manifestations of sarcoidosis and to treat hypercalcemia.
61
Eosinophilic Granuloma leads to? treatment?
• Eosinophilic Granuloma leads to pulmonary fibrosis. No treatment has been shown to be beneficial for this disease.
62
What is alveolar proteinosis? What may cause it? treatments?
• Unknown etiology. Deposition of lipid-rich proteinaceous material in the alveoli. Present with dyspnea and arterial hypoxemia. May occur independently or in association with chemotherapy, AIDS, or inhalation of mineral dusts. Whole-lung lavage may be needed to remove the alveolar material and improve macrophage function. Double lumen tube needed for lung lavage to separate lungs during lavage to optimize oxygenation during the procedure.
63
what types of shock fall under hypo dynamic shock?
hypovolemic shock, cardiogenic shock, and obstructive shock
64
what types of shock / disorders / dz's fall under hyperdynamic shock?
sepsis, severe trauma, anaphylaxis, specific drug intoxications, neurogenic shock, adrenal insufficiency, and severe pancreatitis
65
hypodynamic shock, tell me about the hemodynamics?
o Decreased CI and vasoconstriction
o Decreased CO results in increased oxygen extraction and lactic acidosis
o Organ dysfunction from inadequate blood flow
66
hyperdynamic shock, tell me about the hemodynamics?
o High CI and vasodilation
o Normal or decreased oxygen extraction
o Increased or normal filling pressures depending on volume status and myocardial performance
o Organ dysfunction from maldistribution of blood flow, rather than inadequate blood flow
67
what causes hypovolemic shock and what is the hallmark sign of hypovolemic shock?
o Hemorrhage, dehydration, and massive capillary leak
| o Decreased cardiac filling pressures are the hallmark sign
68
most common cause of cardiogenic shock?
acute MI involving 40% or more of the left ventricle
69
tell me about systolic dysfunction?
* Decreased CO and SV
* Systemic perfusion is decreased, which results in compensatory vasoconstriction and fluid retention...further leading to myocardial dysfunction
* Hypotension decreases coronary perfusion pressure and worsens MI
70
Tell me about diastolic dysfunction?
• Increase LVEDP, pulmonary congestion, and hypoxemia
71
most common causes of obstructive shock?
o Most common cause is pericardial tamponade, acute PE, and tension pneumothorax
72
what two shocks have similar clinical manifestations?
obstructive shock and cardiogenic shock
73
first line pressor for septic shock?
| What is the progression of add on vasopressors?
Norepinephrine the first line vasopressor for septic shock (and cardiogenic)
If MAP < 65 mm Hg, add epinephine
If MAP still < 65 mmHg, add vasopressin 0.03-0.04 U/min
Dobutamine can be added in the presence of myocardial dysfunction or when hypoperfusion persists
74
Traumatic shock is similar to? Tell me about it?
o Similar to septic shock
| o Multifactorial, including a distributive immunologically mediated response to injury as well as shock from hemorrhage
75
what is the lethal triad?
acidosis
hypothermia
coagulopathy
(trauma causes hemorrhage which leads to decreased platelets and factors dysfunction causing coagulopathy on its own and at the same time the hemorrhage causes acidosis and hypothermia which further aggravates factor and platelet dysfunction leading to coagulopathy)
76
Pulmonary embolism treatment?
Thrombolytic therapy indicated
o However, many trauma patients are not candidates for systemic thrombolysis but can have catheter directed thrombolytic therapy
Thoractomy and surgical pulmonary embolectomy
77
causes of PE?
Almost all causes of PE are blood clots that start in the legs (DVT) but PE is a blood clot regardless of where it starts.
78
What does a patient look like (S/S) if they have a PE?
(1) transient dyspnea and tachypnea
(2) pulmonary infarction or congestive atelectasis manifested by pleuritic chest pain, cough, hemoptysis, pleural effusion, or pulmonary infiltrates
(3) right ventricular failure associated with severe dyspnea and tachypnea
(4) cardiovascular collapse with hypotension, syncope, and coma (massive PE)
(5) nonspecific symptoms including: confusion, coma, pyrexia, wheezing, recalcitrant HF, and dysrhythmias
79
what is the bainbridge reflex?
acceleration of the HR when intrathoracic pressure is increased during inspiration and slowing of the HR when the intrathoracic pressure decreases during expiration.
80
occulocardiac reflex?
bradycardia due to traction on eye muscles
81
celiac plexus stimulation causes? (it is a reflex)
bradycardia due to traction on the mesentery
82
prolonged QT interval in men and women?
men is greater than 440ms and women is greater than 460ms (0.44 s and 0.46 s)
83
when is a QT interval associated with toursades?
greater than 500ms
84
antidromic AVNRT means?
wide QRS tachycardia
85
orthodromic AVNRT means?
narrow QRS tachycardia
86
what meds do you NOT want to give if someone has antidromic tachycardia?
DO NOT GIVE adenosine, CCB, β-blockers, or amiodarone
87
What meds can you give if someone has antidromic tachycardia?
DO GIVE procainamide 10 mg/kg then cardiovert if drug therapy unsuccessful
88
What would you do for someone with orthodromic AVNRT?
o perform vagal maneuver, then give adenosine, verapamil, β-blockers, or amiodarone
89
what is 1st degree HB?
delay in cardiac impulse through the AV node
PR interval longer than 200ms
90
what to be careful with or avoid with 1st degree HB?
o Avoid increasing vagal tone
| o Careful of administration of atropine
91
What are the two types of 2nd degree HB?
Mobitz type 1 (WKBCH)
| Mobitz type 2
92
what is Mobitz type 1?
progressive prolongation of PR interval then a QRS (beat) is dropped.
93
what is Mobitz type II?
sudden and complete interruption of conduction (dropped QRS) without prolongation of PR Interval
94
which 2nd degree HB is more dangerous?
Mobitz Type II is more likely to progress to 3rd degree HB esp in the setting of acute MI
95
Anesthetic management of Mobitz type I ?
Atropine if the patient is symptomatic
| If atropine is ineffective, pacing is indicated.
96
Anesthetic management of Mobitz type II?
Temporary treatment include transcutaneous/tranvenous cardiac pacing
Permanent pacemaker
Isoproterenol > Atropine
97
describe third degree HB?
Ps and Qs don't agree then you have 3rd degree.
| no correlation between the P waves and QRS waves
98
Difference between multifocal atrial tachycardia and afib?
Afib has no P waves, MAT does have P waves present.
99
what do you look for on EKG for torsades?
twisting of the peaks
prolonged QT interval is associated with increased risk of torsades.
oscillatory changes in amplitude of the QRS complexes around the isoelectric line.
100
Tx for torsades?
mag. 1-2g over 5 min.
101
what can you see if someone has WPW syndrome?
delta wave! (slurred upstroke to the QRS complex)
* PRI < 120ms
* QRS > 120ms
102
most common tachydysrhythmia seen in patients with WPW syndrome?
AVNRT
| Orthodromic and Antidromic?
103
List some cyanotic shunts?
* Tetralogy of Fallot
* Eisenmenger Syndrome
* Tricuspid Atresia
* Transposition of Great Arteries
* Truncus Arteriosus
* Partial Anomalous Pulmonary Venous Return
* Hypoplastic Left Heart Syndrome
104
list some acyanotic shunting and obstructions?
* Shunting (ASD, VSD, and PDA)
| * Obstructive (Aortic stenosis, pulmonic stenosis, COA, and Ebstein Anomaly) purely obstructive, no shunting
105
right to left shunts result in ?
decreased pulmonary blood flow and hypoxia
106
left to right shunting leads to?
increased pulmonary blood flow (increases PVR), leading to intimal hyperplasia and vascular remodeling (pulmonary HTN, RVH, and eventually CHF)
107
The most prevalent CHD is?
VSD
108
PDA first line treatment?
indomethacin which decreases prostaglandin production and thus causes the duct to close.
109
what keeps ducts open in a CHD heart?
prostaglandins
110
as a CHD, aortic stenosis is due to?
a bicuspid valve compared to what is normally a tricuspid valve
111
aortic stenosis will cause what issue to the LV?
HYPERTROPHY (concentric which means the wall becomes thicker to push out the volumes)
112
difference between concentric and eccentric?
concentric is an increase in wall mass to push against a valve.... (stenosis)
eccentric means an increase in area and thinner wall to accommodate for more volume.... (regurgitation)
113
aortic stenosis you want to avoid?
ketamine bc it may increase HR.
Regional bc it may lead to hypotension.
avoid tachycardia because it decreases filling time.
114
with aortic stenosis you want to treat hypotension with? tachycardia with?
phenylephrine
esmolol
115
Cortication of aorta, preductal vs postductal?
preductal = cyanosis of lower extremity with pink upper extremities (open ductus)
postductal is usually asymptomatic
116
what type of heart failures/ issues are pressure overload issues.
aortic stenosis
| systemic HTN
117
what type of heart failures/ issues are volume overload?
aortic/ mitral regurgitation
118
MCC of diastolic HF?
ischemic heart dz, long standing HTN, aortic stenosis.
119
is systolic HF greatest in men or women?
men
120
Ventricular dysrhythmias are common with systolic HR, this leads to?
LBBB = sudden death
121
What is the hallmark of chronic systolic dysfunction?
Decreased EF
122
systolic HR has relatively fixed SV which leads to?
CO increases dependent on HR
123
is blood pressure maintained in acute or chronic HF?
chronic
124
which type of HF will cause systemic venous congestion?
Right sided HF
125
s/s are peripheral edema and congestive hepatomegaly... what type of HF?
Right sided HF
126
s/s = dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and possibly pulmonary edema... what type of HF?
Left sided HF
127
pulmonary congestion = what type of HF ?
left sided HF
128
management of chronic HF?
* Therapeutic goal: prolong life by slowing or reversing the progression of remodeling
* Lifestyle modifications: dieting, smoking, wt control, exercise, BG control
129
Managing systolic HF?
| what drugs are favorable?
o Beta blockers and ACE inhibitors favorably influence the long-term outcome.
o Other drugs include: Diuretics, Digoxin, Vasodilators, and Statins
130
Managing diastolic HF?
o Therapy is not as standardized as systolic management
| o Lifestyle modification, preload management, rhythm management
131
Acute HF management?
Inotropics are mainstay of treatment.
| Diuretics, loops will rapidly improve symptoms.
132
TEE is best for what type of HF?
Diastolic HF
133
If a patient has HF what will you want to watch intra-op?
fluids bc it can worsen HF
134
In someone who has had a heart transplant (denervated heart) increases in HR are best achieved by what kind of drugs?
Direct acting beta adrenergic agonist = Epi / Isuprel
135
what type of murmur is an incompetent (regurges) mitral or tricuspid valve?
systolic murmur
136
What type of murmur is a stenotic aortic or pulmonic valve?
systolic murmur
137
what type of murmur is a stenotic mitral or tricuspid valve?
diastolic murmur
138
what type of murmur is an incompetent aortic or pulmonic valve?
diastolic murmur
139
Require slow HR to prolong duration of diastole and improve left ventricular filling and coronary blood flow?
aortic and mitral stenosis
140
Require afterload reduction and somewhat faster HR to shorten the time for regurgitation?
aortic and mitral regurgitaion
141
normal aortic valve area is?
2.5-3.5 cm2
142
severe aortic stenosis patients are SAD, what does this mean?
syncope
angina
dyspnea on exertion
143
Do you want hypotension with AS why or why not?
o Hypotension reduces coronary blood flow and results in myocardial ischemia
144
What drugs do you WANT to use for induction with AS?
o Etomidate and benzodiazepines
o An opioid induction agent may be useful if left ventricular function is compromised
o Ketamine may induce tachycardia and should be avoided
145
Diagnosis for STEMI?
o Ischemic symptoms
o Pathological Q waves noted on EKG
o EKG changes indicative of new ischemia such as LBBB or ST changes
o New onset of myocardium or regional wall abnormality evidenced by imaging
146
S/S of STEMI?
diaphoresis, anxiety, sinus tachycardia, hypotension, notable dysrhythmias, and rales
147
Causes of NSTEMI?
o Nonocclusive thrombosis (from coronary plaque)
o Vasoconstriction (from cocaine use, cold, variant angina)
o Atherosclerosis
o Inflammation (ex. vasculitis)
o Increased oxygen demand due to myocardial ischemia
148
Is thrombolytic therapy indicated for UA/NSTEMI?
No due to increased risk of death.
149
How do you confirm the diagnosis of perioperative myocardial infarction?
New wall motion abnormality on EKG with a rise in troponin levels
150
Most dangerous ectopic beats are?
| What could they lead to?
PVCs that occur during T wave
* Also known as R-on-T phenomenon
* Can lead to vtach or vfib
151
What is a normal troponin?
0.00-0.04 (0.03)
152
What gas will you not use with pulmonary hypertension and risk of embolism?
Nitrous
153
What patients receive cardiac transplantation?
* End-stage heart failure
* Valvular heart disease
* Congenital heart disease patients
154
If you've had a cardiac transplant are you more or less responsive to direct acting catecholamines?
more prone to respond to direct acting catecholamines. (less intense response to indirect acting catecholamines such as ephedrine).
155
MCC of myocardial remodeling?
ischemic injury
156
Tx for myocardial remodeling?
ACE inhibitors which promote the reverse remodeling process.
157
what causes progression of HF?
maladaptive mechanisms ultimately leave to myocardial remodeling --> progression of HF
158
management of heart disease, is there a single best answer?
depends on what is wrong with their heart, functional status and comorbidities.
goal is to optimize oxygen delivery to all organs
159
low risk heart dz, what changes about anesthesia monitoring?
standard monitoring and care
160
moderate to sever risk heart dz, what changes about anesthesia monitoring?
special attention even with minor surgery (invasive monitoring, CVL, TEE, inotropic and vasopressor drugs, etc.)
161
`What two types of heart valves are there?
mechanical and bioprosthetic.
porcine or bovine (or homografts which are preserved human aortic valves)
162
tell me about mechanical heart valves?
lasts 20-30 years
require long term anticoagulation
good choice for someone who is going to live longer than 10-15 years and already needs anticoagulation
163
tell me about bioprosthetics?
valves last 10-15 years
long term anticoagulation is not necessary
preferred in elderly patients and those who cannot tolerate anticoagulation
164
Antibiotic prophylaxis for infective endocarditis is recommended only under a very few conditions, what are those conditions?
(previous infection, congenital heart disease, cardiac transplant)
dental procedures involving manipulation of gingival tissues or periapical regions of the teeth.
invasive procedures in the resp. tract or infected skin or musculoskeletal tissue.
165
in relation to endocarditis antibiotic prophylaxis is NOT recommended for what type of procedures?
genitourinary or gastrointestinal tract procedures.
166
what is the treatment for SVT?
ADENOSINE
167
Treatment of sympotmatic bradycardia?
atropine
168
treatment for AF, VF, and pulseless VT?
Amiodarone
169
CCB include which two drugs?
Verapamil and diltiazem
170
What is Verapamil the treatment for?
narrow-complex tachycardia (SVT) in patients in whom adenosine therapy have failed, atrial tachydysrhythmias, and reentrant dysrhythmias
171
What is digoxin used for?
Cardiac glycoside used for the tx of CHF and AF (but does not convert AF to sinus rhythm)
172
• Co-existing disease states that can contribute to digitalis toxicity include?
hypothyroidism, hypokalemia, and renal dysfunction
173
What is dopamine used for?
Tx of symptomatic bradycardia unresponsive to atropine
174
Potent inotrope, chronotrope, and vasopressor describes?
epinephrine
175
Functionally it has potent β1- and β2-agonist actions but lacks any α-adrenergic properties, this describes what drug?
Isoproterenol
176
2nd line drug in the treatment of symptomatic bradycardia unresponsive to atropine
Isoproterenol
177
Treatment of VT and AF or atrial flutter in patients with WPW syndrome?
Sotalol
178
```
1. The ascending reticular activating system (ARAS) involves all the following neurotransmitters, EXCEPT
A Dopamine
B Galanin
C Acetylcholine
D Histamine
E Serotonin
F Norepinephrine
```
B. Galanin
