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Inhalation Agents Flashcards

1
Q

High Solubility means

A

Blood acts as a reservoir and it stays in the blood and will not get to the brain

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2
Q

what does uptake do?

A

it counters the pressure from the alveoli – creating a huge reservoir

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3
Q

what will decrease in CO do to your IA?

A

pt with poor EF perfusing much less will have higher alveolar concentration of IA = then it will have higher brain concentration BUT will get delivered slower

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4
Q

Name the Inhalation agents

A
  • Isoflurane
  • sevoflurane
  • desflurane
  • nitrous oxide
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5
Q

What is the ideal inhalation anesthetic

A
  • Poorly soluble
  • nonpunget
  • non-flammable
  • inexpensive
  • easy to produce
  • potent
  • environmentally safe
  • no hepatic metabolism
  • not a trigger for MH
  • not emetogenic
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6
Q

MAC is defines as

A

minimal alveolar concentration

  • alveolar concentration at which 50 % of subjects move in response to noxious stimulus
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7
Q

Factors Increasing Anesthetic Requirements: Drugs give 4 samples

A
  1. Amphetamine (acute use)
  2. Cocaine
  3. Ephedrine
  4. Ethanol
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8
Q

Factors Increasing Anesthetic Requirements is highest at age ______

A

age 6 months

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9
Q

Factors Increasing Anesthetic Requirements: Electrolytes and Temperature

A
  1. Hypernatremia
  2. Hyperthermia
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10
Q

Factors Increasing Anesthetic Requirements: Genetics

A

Red Hair

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11
Q

Factors Decreasing Anesthetic Requirements 12 DRUGS

A
  1. Propofol
  2. Etomidate
  3. Barbiturates
  4. Benzodiazepines
  5. Ketamine

. Alpha 2 agonist (clonidine, dex)

  1. Ethanol
  2. Opioids
  3. Amphetamines (chronic use)
  4. Lithium
  5. Verapamil
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12
Q

MAC fractions / multiple of inhalation agents are roughly ______

A

additive

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13
Q

MAC that prevents movement in 95% of patients in incision. with no other medications administered concurrently

A

1.3 MAC

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14
Q

What is the MAC of Isoflurane

A

1.17%*

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15
Q

What is the MAC of Sevoflurane

A

1.80%

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16
Q

What is the Mac of Desflurane

A

6.6%

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17
Q

What is the MAC of Nitrous Oxide

A

104%

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18
Q

The average alveolar concentration permitting voluntary response to command. “ Open your eyes, breathe”

A

MAC awake

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19
Q

MAC awake for most modern IA

A

1/3 MAC

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20
Q

The concentration at which a patient can remember events; This is the point at which patient loses ability to learn

A

MAC aware –> generally patient will move and follow commands before they can make a memory

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21
Q

MAC- BAR: Average alveolar concentration which (autonomic response)

A

BLUNTS AUTONOMIC response

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22
Q

Addition of fentanyl 1.5-3 mcg/kg reduces MAC-BAR by approx _____ %

A

50

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23
Q

MACaware is related to 1._____ not 2.______

A
  1. amnesia 2. consciousness
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24
Q

Sevo MAC aware

A

<0.6%

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25
Sevo MAC awake
0.6%
26
Sevo MAC
1.80%
27
Sevo MAC - BAR
2.88%
28
N20 MAC aware
\<60%??
29
N20 MAC awake
60%
30
N20 MAC- BAR
Not possible
31
Indirect but reliable measure of **PBr**
**Alveolar Partial Pressure**
32
is the setting of the dial of the partial pressure of the alveolar the same as inspired concentration?
NO The setting of the dial of the Partial pressure of the alveolar is **NOT** the same as the inspired **CONCENTRATION**
33
The FI is NOT the same as the ______ \_\_\_\_\_\_
alveolar concentration
34
What is the our most distal (exhaled concentration by gas alveolar) measurement of partial pressure?
**Alveolar Partial pressure**
35
Metabolism of IA is \_\_\_\_\_
minimal
36
At equilibrium, between 2 phases, the partial pressure is _____ in both phases
equal
37
The principal objective of inhalation anesthesia
is **to achieve a constant and optimal brain partial pressure (as reflected by the PA** …or really the ET concentration by gas analyzer).
38
## Footnote **PA is used as an index of:**
* Depth of anesthesia * Recovery from anesthesia * Anesthetic equal potency (MAC)
39
The depth of anes induced by IA depends primarily on the \_\_\_\_
**partial pressure**
40
What determines Alveolar Partial Pressure?
delivery into the alveoli minus loss of drug into blood uptake
41
**Input** depends on:
* **The inhaled partial pressure** * **Alveolar ventilation and FRC** * **Characteristics of the anesthetic breathing system**
42
**Uptake** depends on:
1. **Solubility** of the anesthetic in body tissues of the anesthetic in the body 2. **Cardiac** output 3**.Alveolar to venous PP** differences (A-vD)
43
Initial administration of an anesthetic to **offset the impact of uptake** requires
A **high PI is required** during **INITIAL administration** of an anesthetic to **offset** the impact of **uptake**
44
Higher PIs will help you achieve the desired PA more quickly—accelerating the rate of rise of the PA PBr This is called _______ and is related to the **concentration effect**
**OVERPRESSURE**
45
As the A-vD decreases, the rate of uptake into blood ______ and the PI should be ______ to avoid overdose
1. decreases 2.decreased
46
If you use the overpressure technique, keep your hand on the ______ until you have dialed the concentration back down to avoid problems
vaporizer
47
**Increasing alveolar ventilation** ↑ the rate of rise of the ____ toward the \_\_\_
**1. PA ** **2.PI -** Agents taken up by the blood is rapidly replaced with fresh gas mixture
48
What IA causes **nausea?**
**ALL OF THEM**
49
It is defined as the **concentration at 1 atm that prevents skeletal muscle movement to a painful stimulus** is it a form of **ED50**?
**MAC** **Minimal Alveolar Concentration** --\> Alveolar concentration at which 50% of subjects move in response to a noxious stimulus
50
**T/F** The **prevention of movement in MAC** is cerebral mediated
**False** The **prevention of movement** with **MAC** is **SPINALLY MEDIATED.**
51
What happens to anesthetic requirements if you are a chronic ETOH use?
you will increase your amount of anesthetic requirement if for a **chronic ETOH**
52
0.5 MAC N20 + 0.5 MAC ISO = 1 MAC What is the relationship of combining two inhalation agents? What is the MAC where 95% of patients are prevented from moving on incision?
MAC fractions/ multiple of inhalation agents are roughly **additive** **1.3 MAC** prevents movement in 95% of patients on incision
53
Does **N20 contribute** more or less to MAC in advanced age?
**N20** contributes **MORE** to **MAC** in **advanced age**
54
What is the relationship of **opioids** with **VA?**
**Synergistically** **decreases** requirements
55
What are these numbers?
% is equal to 1 MAC being dialed in the vaporizer
56
When you awaken your patient and you started asking them to **squeeze their hands or open their eyes** -- and they were able to what level is this of MAC?
MACawake
57
Does your patient that just followed commands [MACawake] able to remember?
**NO.** They are not yet MACaware They really **do not know whats going on**
58
This is the point where patients start **remembering events**
## Footnote **MACaware**
59
Why do patients in PACU keep asking the nurse the same thing over and over again but are able to follow commands
Generally, the patient will **move and follow commands before they can make a memory**
60
This is the MAC level in which the autonomic system effect is blunted to a noxious stimuli
**MAC -BAR** Average alveolar concentration **B**lunts **A**utonomic **R**esponse to a noxious stimulus (incision)
61
If a patient is in **MAC -BAR** what will you **no longer see?**
Patient on **MAC -BAR will NOT have a change** in **Blood Pressure** **Heart Rate**
62
How is Nitrous delivered?
**Nitrous** is delivered in ***_L/ MIN_***
63
How much is the MAC-BAR50 for Sevo when combined with 66% of N2O?
2.2 MAC- BAR50 for Sevo combined with 66% of Nitrous
64
is it possible to have a MAC-BAR with Nitrous?
It is **not possible** to have a **MAC-BAR** from **Nitrous**
65
How many TIMES of your MAC to achieve MAC-BAR?
MAC - BAR is usually **1.6X** your MAC i.e Sevoflurane 1.8% MAC X 1.6 = 2.88%
66
67
What is **PA?**
**Partial Pressure** in the **alveoli**
68
IA from the **vaporizer to the alveoli is called**? is it the same as the alveolar concentration?
**F****I =** inspired concentration **IA FROM THE VAPORIZER TO THE ALVEOLI** it is **not the same** as the **setting on the dial** it is **not the same** as the **alveolar concentration (FA)**
69
What equilibrates?
**Partial Pressure** is what equilibrates
70
What determines the depth of anesthesia? volume percent or partial pressure?
**Partial Pressure** **it is the equilibriation of Partial pressure**
71
What is **UPTAKE?**
**Abrosption (UPTAKE)** from the **alveoli into pulmonary capillary blood**
72
What is PA used as an index of ?
**Depth** of Anesthesia **Recovery** from anesthesia Anesthetic **equal potency**
73
What are the tissue compartments?
74
Determinants of PA
**Delivery into the alveoli (INPUT)** minus **loss of drug into the blood (UPTAKE)** FA= INPUT - UPTAKE
75
**INPUT** depends on **C.A.T**
* **C**haracteristics of the anesthetic breathing system (tubing, loss in the atmosphere) * **A**lveolar ventilation or Functional Residual Capacity (FRC) * **T**he inhaled pressure (PI)
76
How can you **induce anesthesia at the rate** that you want?
1. **Increase** the **administered** amount [alveoli can fill up faster] 2. **Slow down the leak** [the **less soluble** the drug the faster the alveoli can fill up]
77
What is **"OVERPRESSURE"**
delivering a higher percentage --\> the higher the faster the alveolar concentration shall be
78
What will happen if you increase alveolar ventilation?
**Î the rate** of **rise** of the **PA** towards **PI** **Agent taken up by blood is rapidly replaced with fresh gas mixture**
79
What happens to PBr during **hyperventilation?** **(hypocapnia)**
**decrease CBF** and may **delay** the rate of **rise of PBr**
80
What is the ventilatory pattern of change in patients receiving IA? on Spontaneous Ventilation?
**IA produces DD depression of ventilation** --\> pt takes **lower TV and increased RR** --\> **protective mechanism,** as the body start taking IA the body starts decreasing TV on Spont ONLY
81
Interpret this chart. What are the minute ventilations?
1. Opiods = increase in TV, decrease in RR 2. **Breathing IA = decrease TV, increase RR** NORMAL BREATHING MV: 5000ml/mim Opiods: 4750 ml/min IA: 5000 ml/min
82
What is this?
CO2 response curve
83
**Anesthetic Breathing System affects inpu**t what are the **characteristics** of the breathing system which **increase the rate of rise of PA?**
## Footnote –**Volume** of the external breathing system –**Solubility** of the **inhaled anesthetic** into the components of the breathing system –**Gas inflow (FGF)** from the anestheticmachine
84
T/F Gas flows is directly proportional to PA?
**•High fresh gas flows will ↑ the rate of rise of the PA** ## Footnote * Faster filling of the volume of the anesthetic circuit (soda lime canister,breathing bag…) * Greater amount of drug per unit of time to replace gases that are taken up at the alveoli
85
How can solubility affect the rate of rise of PA?
**Anything that gets absorbed in the system can affect the rate of rise in the PA** –This slows the rate of rise of the PA –At the **conclusion** of the procedure, **reverse gradients** will delay the rate of the fall of the PA (delay recovery)
86
87
What denotes solubilities of IA in the blood and tisses?
**Ostwald partition coefficient** * These distribution ratios describe how anesthetics distribute between 2 phases **(PPs, not concentrations) equilibrate!** at 37°C at atmospheric pressure.
88
Blood: Gas partition coefficient of Iso is? what does this mean?
Blood:Gas partition coefficient, 1.46(Iso) * At equal partial pressures, the amount of drug/volume in the blood is ~1.5 times that in the alveolar gas Isoflurane is highly soluble
89
What is is the Blood:Gas partition coefficient of Halothane Isoflurane Sevoflurane Desflurane Nitrous Oxide
90
What is the best IA to use for a patient with a large body habitus?
**Desflurane** ***"fast on fast off"*** as compared to a drug that has higher solubility and has a possibility of depot build-up
91
Work hoarse for most cases?
**Sevoflurane**
92
T/F Increased solubility is inversely proportional to the rate and rise of the PA towards the PI
True
93
Classify the following IAs according to solubuluty Soluble Intermediately Poorly soluble
Soluble- none of the modern inhaled agents **Intermediately soluble -- Iso** **Poorly soluble - Sevo, Des, N20**
94
FA/ FI Curves
95
How long does it take for **95% equilibration of PP between blood and tissue phases?**
**3 TIMES CONSTANT**
96
What does fat do to anesthetics?
FAT has an enormous capacity to uptake anesthetics and can take up to 24- 48 hours to equilibriate
97
What is the relationship of **CO** and anesthetics? what will it do to the rate of **rise of PA** How about **induction?**
**↑CO results in ↑ uptake of anesthetic into blood from the alveoli** ## Footnote –The rate of ***rise of PA will slow*** •Inhalation **induction is slow** **↓CO** results in **↓ uptake** of anesthetic into blood from the alveoli –The rate of rise of **PA is fast** •Inhalation **induction is rapid**
98
What is the reason behind this statement? •**Changes in CO influence** the **rate of rise of PA** toward **the PI** **of soluble anesthetics more than poorly soluble anesthetics**
**N2O** has a rapid rise in PA regardless of CO **•This is due to its lack of potency and the high inspired concentrations delivered (70% for N2O vs. 1.15% for Iso)** - N20 will have a rapid rise because of the higher volume of anesthetics being delivered
99
What is the effect of VA to CO? What may occur?
**VA can depress CO** - when **CO is depressed,** there will be a **decrease in uptake** leading to an **increase in PA** POSITIVE FEEDBACK –As the Pa rises, increasing cardiac depression results in more rapid rise in PA •Excessive depth of anesthesia may result, especially if combined with mechanical ventilation!
100
101
What affects delivery into the alveoli?
**INPUT**
102
**What affects the lost of the drug in to the blood?**
**Uptake**
103
## Footnote **What is the concentration effect?**
* We are looking at the rate of rise of the PI and how to can impact the rise of PA * The higher the PI, the more rapidly the PA approaches the PI **(overpressure)** * **concentrating effect; overpressure and augmentation of gas inflow** * temporary phenomenon
104
**Second Gas Effect**
The use of nitrous during the induction to hasten the effects of sevo [drug of choice]
105
If the **second gas is O2**, the result is
**Alveolar Hyperoxygentaion**
106
What happens if the **second gas is a volatile anesthetic**?
**results in a more rapid rise in PA toward the PI (more rapid inhalation induction)**
107
T/F Metabolism is desirable
**FALSE BAD**
108
What is the rule of 2
**Desflurane 0.02%** **Isoflurane 0.2%** **Sevo 2%** - undergoes hepatic biotransformation -
109
How do we **eliminate IA** from the body?
MAJORITY through **exhalation** **-** Percutaneous loss (and loss from open wound) of IAs (like CO2) is minimal (\<1%) and does not influence the rate of rise or recovery from IAs
110
What is the amount of metabolism of inhaled anesthetics? Halothane Sevolflurane Isoflurane Desflurane Nitrous Oxide
111
During recovery from anesthesia, what do you want to see? What is the **difference** between induction and recovery?
**The rate of decrease in the brain as reflected by the PA** -- You can overpressure to speed induction, **but you cannot under pressure (deliver \<0%) to speed recovery-**- -- you cant make a negative pressure --
112
When can you achieve equilibrium in all tissues?
Equilibrium **MAY NOT BE** achieved in all tissues at the conclusion of surgery (muscle, fat)
113
When does **fat** continue to **take up** anesthetic? what is the **effect** of that in **recovery?**
Fat may continue to take up anesthetic as long as **Pa is greater than the tissue partial pressure** **- it initially speeds the decrease in PA**
114
115
Which patient will recovery faster? The patient Iso or the one given sevo?
The patient is given Sevo -- Time to **recovery** is much **longer** for the more **soluble** anesthetics compared to poorly soluble anesthetics --
116
What will happen to the **absorbed** components of the **breathing system?** What will it do to the rate of decrease of PA?
Anesthetics that has been absorbed into the components of the breathing system **will return to the gases in the breathing circuit** and **SLOW t**he rate of decrease of the PA **= slower recovery=**
117
How can you blow off the gas? How can you hasten the gas being blown off the absorbed breathing system?
Increase **fresh gas flows (FGF) to (\>5L/min)** - this will **dilute** the agents returning into the inspired gases from components of the breathing system and **speed the rate of decrease of the PA**
118
We know that anesthesia is not ON and OFF Adjustments (titration) are made based on (3)
* The patient response to the drug * Interactions with other medications * The degree of stimulation (surgical, ETT)
119
What do you want to do at the conclusion of surgery?
* **Gradually decrease the percentage** * Sx done: suturing, putting dressing --\> less stimulating * just waiting for the patient to wake up --\> least amount of stimulation
120
Elimination of IAs depends on: (2)
## Footnote **Elimination of IAs depends on** **- Length of administration** **- Blood: Gas Solubility of the agent**
121
In less than 5 minutes how much would be the initial decrease of IA Iso, Enf, Sevo and Des?
The initial decrease **(50% decrement time)** for **Iso, Enf, Sevo, and Des in \<5 mins and does not vary considerably with the duration of the anesthetic**
122
The **initial** phase of **elimination** is a function of?
The **initial phase** of elimination is a **function of alveolar ventilation**
123
What is the 90% decrement time for Iso, Sevo, Desflurane after 6 hours of anesthesia?
124
When is the major differences in elimination among these agents?
The major differences in elimination among these agents is **during the final 20%** of the elimination process
125
What is the Meyer -Overton Hypothesis?
The **MAC** of a volatile substance is **inversely** proportional to its **lipid solubility** **-POTENCY CORRELATES WITH LIPOPHILICITY -**
126
What is 5 Angstrom Theory?
127
128
Which receptors do volatiles act on?
129
Amnesia is mediated by?
Probably **NOT spinal cord mediated** memory is lost at concentrations less than MACawake -- always anetrograde amnesia--
130
Belief that inhaled anesthetics act by effects at multiple sites
**Multisite Theory of Narcosis**
131
Belief that anesthetics act on no more than 2 - 3 sites to produce a specific effect
**Unitary Theory of Narcosis**
132
What is the Protein Based Mechanism?
**Current consensus for MOA** - **GA is produced by membrane bound protein interactions in the brain and spinal cord** **Brain: GABA -A** **VA will stimulate inhibitory receptors and inhibit stimulatory receptors** **Spinal Cord: Glycine, NMDA inhibition, Na Channel inhibition--\> produces immobility mostly in the ventral horn**
133
MOA of N20?
**N20: NMDA antagonism, Potassium 2P- channel stimulation** **DOES NOT STIMULATE GABA -A RECEPTORS**
134
Effects on Systems amongs VA?
**Similar effects among different agents at equipotent concentrations** - **especially during the maintenance** phase of anesthesia - Co- existing diseases, differences in age, degrees of surgical stimulation, concurrent drug therapy, etc. may cause variations in responses
135
how is MAP changed? What is the reason the decrease in MAP How does N20 change the map?
**decrease in MAP is mainly affected( d/t) the the decrease in SVR**
136
Which IA will you see an **increase in HR**?
Iso and Des are a little more irritating
137
Which IA will cause a decrease in HR? is it mac related?
Sevo greater than MAC \> 1.5 you will see an increase in HR comparable to Des and Iso
138
How is **Cardiac Output/ Index affected by VA?**
## Footnote **minimal**
139
How can you lessen the cardiac effects of the VA?
By using **N20** as an **additive**
140
When do you see this most?
**Desflurane** ## Footnote -- when mac was **abruptly increased** you can see a **rapid rise in HR** - rise in HR is **expected but more exaggerated** with an increase in concentration of Des . **- this is related to SNS activity**
141
Myocardial Conduction effects of VA
NO sensitization as compared to Halothane
142
Which drug do you generally avoid in patients with congenital prolonged QT syndrome? why?
Dr. Cansino generally do not consider this with avoiding Sevo "all drugs will prolong QT "
143
What VA may induce Coronary Steal?
Coronary steal; as the myocardial demand increases healthy vessels will dilate. "stealing away blood from ischemic areas and directing it to healthy issues" All VA produces anesthetic preconditioning
144
how does minute ventilation correlate with VA?
**Similar Minute Ventilation** **does not mean similar VA**
145
How is the response to CO2 affected? How is the response to O2 affected?
146
Which **IA** decrease **bronchial constriction**?
**ALL** potent IAs **decrease bronchial constriction**
147
What do Iso and Des do to the bronchioles? why? How can it be attenuated?
148
What do IAs do to HPV?
HPV decreases V/Q mismatch. **IAs inhibit HPV** especially at greater than **1-2 MAC**
149
What kind of chest wall changes do you see?
150
N20 effects on CBF and CMRO2
mildly excitatory
151
Effects of VA to CNS
152
You are doing a crainy how do we decrease the ICP if we are using VA?
We do not like that -- hyperventilate make the patient hypocarbic to make the cerebral vessels constrict --\> decrease in blood flow --\> decrease in icp **all VA increase ICP exceeding 1 mac**
153
How does VA affect autoregulation?
**Autoregulation is impaired at concentrations more than A MAC [50 - 150 MAP]** **- However cerebrovascular response to PaCO2 is maintained**
154
155
## Footnote **IAs effects on Evoke Potentials?**
156
Remember this EEG changes !
possible that this VA can cause epileptic properties
157
**Neuromuscular Effects**
**VA will potentiate the muscle relaxant effects**
158
What triggers MH?
**ALL VA!** Hal and SUCCS
159
Which VA can potentiate a more severe hepatic injury?
**\*** all VA agents produce dose-dependent reductions in hepatic blood flow and mild elevations in LFTs **Hal, Iso , Des** ---\> mostly due to hepatic necrosis. --\> **TRIFLUOROACETATE** BAD!-- binds to hepatocytes --\> hepatic injury was what caused problems
160
What causes immunologic response that results in hepatic necrosis?
**_TRIFLUOROACETATE BINDS COVALENTLY TO HEPATOCYTES_** TRIFLUOROACETATE-HEPATOCYTE COMPLEX triggers immune response
161
162
Effects on System - Renal
decrease SVR decrease renal perfusion
163
Sevo is **metabolized** to \_\_\_\_?
**Sevo** is metabolized to **inorganic F**
164
What does **Sevo** do to **renal function**
**prolonged Sevo** anesthesia **does not impair renal** function -- not so much of an issue because SEVO is only 2% metabolized by the liver --
165
This **toxin causes nephrotoxicity?** what are the signs of nephrotoxicity
**Inorganic F greater than 50 mmol/L**
166
167
another by-product by Sevo that may cause nephrotoxicity
168
What produces more relaxation as compared to Halothane?
Ether derivatives produces more skeletal muscle relaxation than Hal
169
Effects of N2O at skeletal muscles
**N2O** produces s**keletal muscle rigidity at high concentrations**
170
Will N20 enhance NMBAS?
**N20 DOES NOT** ENHANCE NMBAS
171
Des MH can manifest until?
MH **may not manifest immediately** Post Des MH reported to manifest 3 hours post anesthetic
172
Effects on Obstetrics
**ALL** **TOCOLYTICS** **dose-dependent** decreases in uterine contractility and blood flow **modest: 0.5 mac** **Substantial effect at \>1.0 MAC** n20 does not produce tocolytic effects
173
**Effects on Immune System** What does **N2O** do? **VAs** and **measles?** **whats the cause?**
174
What IA is teratogenic and best avoided in pregnancy esp. on the 1st semester
**N2O** due to inhibition of DNA synthesis
175
N20 effects on Bone Marrow
not relevant since you don't give N2O for more than 24 hours.
176
N20 and Peripheral Neuropathy
**ability of N2O to oxidize irreversibly the cobalt atom of the vitamin B12 such that the activity of B12 enzyme is decreased** --\> knowledge thing than clinical implications
177
Which organ has the most decreased O2 requirement?
**O2 requirements decrease similarly among the VA** **- HEART -** requirements are decreased more than other organs
178
How much is metabolized depends on the agent
179
IMPORTANT! **CARBON MONOXIDE** **what produces more?** **what can increase Carbon monoxide production?**
when delivering VA and it interacts with CO2 absorbent **Carbon monoxide is produced during degradation by CO2 absorbens** **Des\>Enf\>Iso** 1. **Carbonmonoxide will bind to iron and pulse Ox will look normal--\> if the CO2 absorbent in** **the system is dry that can accelerate the production** 2. **if temp of CO2 absorbent is high** 3. **low gas flows and increased metabolic production of CO2** 4. **or high FGF for a long period of time and that causes desecration of the carbon dioxide absorbent** 5. **type of CO2 absorbent**
180
Pharmacoeconomics What are the cost considerations?

Anesthesia Pharm (25 decks)

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