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IV anesthetics Flashcards

1
Q

IVAA which has intrinsic analgesic property

A

Ketamine

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2
Q

IVAA which has antiemetic and appetite stimulating property

A

Propofol

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3
Q

IVAA with amnestic and anxiolytic property

A

Midazolam

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4
Q

Adjuvants for IVAA to produce TIVA

A

Opioid

LAA

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5
Q

MoA of Barbiturates

A

Depress RAS
Inhibit ACh
Enhance GABA

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6
Q

First barbiturate used

A

Hexobarbital

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7
Q

Gold standard of IV anesthetic inductional agent

A

Thiopental

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8
Q

Advantages of thiopental

A

Fast induction time
Fast recovery time
Fast elimination time

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9
Q

Disadvantages of thiopental

A

Localized pain on injection
Excitatory side effect
Induce tachycardia

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10
Q

IVAA widely used in dental anesthesia and day-case surgery

A

Thiopental

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11
Q

Effect of replacing Oxygen (oxybarbs) by Sulfur (thiobarb)

A

Increase lipid solubility

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12
Q

Barbiturate available for rectal administration

A

Thiopental

Methohexital

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13
Q

Barbiturate available for IM

A

Pentobarbital

Secobarbital

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14
Q

Property of Thiopental

A

High PPB
High lipid solubility
High non-ionized fraction

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15
Q

Redistribution time of thiopental

A

20-30 min

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16
Q

Effect of repeated dosage on redistribution

A

Peripheral compartment saturates

DOA becomes dependent on elimination

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17
Q

What does awakening depend upon?

A

Redistribution

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18
Q

What does recovery of psychomotor function depend upon?

A

Metabolism

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19
Q

More rapidly metabolized barbiturate

A

Methohexital (3-4X)

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20
Q

Factors that determine elimination of drug and recovery time

A

Elimination of drug from central compartment
Amount of drug present in the peripheral compartment
Rate of redistribution from peripheral into central compartment

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21
Q

Effect of high PPB on elimination

A

Decreases glomerular filtration

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22
Q

Effect of Barbiturate on CVS

A

Fall in BP
Rise in HR
Maintained CO
Sympathetic induced vasoconstriction (Increased PVR)

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23
Q

Factors that determine CVS effects of barbiturates

A

Volume status
Baseline autonomic tone
Pre-existing CVS disease
Rate of injection

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24
Q

Effect of Intra-arterial injection of barbiturate

A

Crystal formation in artery and capillary
Intense vasoconstriction
Thrombosis
Tissue necrosis

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25
Remedy for Intra-arterial injection of barbiturate
``` IA injection of lidocaine Regional sympathectomy (brachial plexus block) Heparinization ```
26
Effect of Barbiturate on Respiratory system
Decrease response to hypercapnia and hypoxia Does not completely depress airway reflex Apnea UAW obstruction (sedation)
27
Barbiturate more commonly associated with laryngospasm and hiccup
Methohexital
28
Cause for Bronchospasm after induction of thiopental + Remedy
Cholinergic nerve stimulation Histamine release Direct bronchial smooth muscle stimulation Remedy Atropine pre-treatment
29
Effect of Barbiturate on CNS
Decrease CBF + CMRO2 Decrease ICP Increased CPP (drop in ICP exceede drop in MAP)
30
Which barbiturate relates a sense of taste of garlic/onion during induction
Thiopental
31
Which group of IVAA has an anti-analgesic effect (lower the pain threshold)
Barbiturates
32
Which IVAA are known to develop tolerance and dependence
Barbiturate | Ketamine (partial tolerance)
33
Which barbiturate induces involuntary muscle contraction)
Methohexital
34
What is the effect of Barbiturate on Renal system
Reduce RBF and GFR proportional to fall in BP
35
What is the effect of Barbiturate on Liver
Reduced Hepatic BF Liver enzyme induction upon chronic exposure Increase metabolic rate of some drugs (digitoxin)
36
Which group of barbiturates evoke mast cell histamine release
Thiopental (Sulfur containing barbiturate)
37
What are drugs that could increase/potentiate barbiturates?
``` Sulfonamide Ethanol Opioids Antihistamine Other sedatives ```
38
Propofol (Vs Thiopental)
Higher lipid solubility Faster onset Rapid recovery Less hangover
39
Adjuvants of Propofol
10% soybean oil 2. 25% glycerol 1. 2% egg Lecithin
40
Remedy of pain on injection of propofol
Using larger veins | Prior administration of LAA or opioid (fentanyl, remifentanil)
41
Sodium metabisulfite in propofol
Newer formulations Antimicrobial additive Less pain on injection
42
Concentration and Dose of Thiopental induction
2.5-5% | 3-6 mg/kg
43
Concentration and Dose of Thiopental sedation
2. 5% | 0. 5-1.5 mg/kg
44
Concentration and Dose of Methohexital induction
1% | 1-2 mg/kg
45
Concentration and Dose of Methohexital sedation
1% | 0.2-0.4 mg/kg
46
Dose of Propofol induction
1.5-2.5 mg/kg
47
Reasons for higher induction and maintenance dose for children for propofol
Large central distribution volume | Higher clearance rate
48
IVAA with a subjective feeling of well-being (euphoria)
Propofol
49
Metabolism of propofol
10X clearance rate of thiopental Clearance exceeds hepatic BF (extrahepatic metabolism) Conjugation in liver results in inactive metabolite
50
Elimination of propofol
Eliminated by renal clearance
51
Effect of moderate cirrhosis and chronic renal failure on propofol
Not much effect on its pharmacokinetic property
52
Infusion of propofol for long-term sedation of children or neurosurgical patient
Lipemia Metabolic acidosis Death
53
Effect of Propofol on CVS
``` Drop in SVR Drop in contractility Drop in preload Vagally mediated reflex bradycardia More pronounced hypotension Coronary steal syndrome ```
54
Effect of Propofol on Respiratory system
``` Profound depressant Apnea at induction Depress UAR Laryngeal placement without paralysis Histamine release ```
55
Effect of Propofol on CNS
``` Decrease CBF Decrease ICP Decrease IOP Anticonvulsant No tolerance development ```
56
Drugs that are potentiated by Propofol
NDMRs
57
MoA of Propofol
Facilitate GABA
58
MoA of Etomidate
Depress RAS | Disinhibitory effect on extrapyramidal motor activity
59
Dosage of Etomidate for Induction
0.2-0.5 mg/kg
60
Metabolism of Etomidate
Hepatic microsomal enzyme Plasma esterase Fast metabolism (5X of thiopental)
61
Excretion of Etomidate
Primarily excreted in urine
62
Which IVAA has minimal effect on CVS
Etomidate
63
Effect of Etomidate on Respiratory system
Less respiratory depression (unless combined with opioid)
64
Effect of Etomidate on CNS
Decrease CBF, CMRO2 Decrease ICP CPP well maintained Postoperative nausea and vomiting
65
Which IVAA leads to adrenocortical suppression
Etomidate
66
Which drug prolongs the half-life of Etomidate
Fentanyl
67
MoA of Ketamine
NMDA antagonist Blocks polysynaptic reflexes in the SC Inhibits excitatory NT
68
Which IVAA produces dissociative anesthesia
Ketamine
69
Two isomers of Ketamine
S+ and R- | S+ more potent anesthetic and analgesic
70
Dosage of Ketamine Induction IV
1-2 mg/kg
71
Dosage of Ketamine Induction IM
3-5 mg/kg
72
Dosage of Ketamine Sedation IV
0.1-0.5 mg/kg
73
Dosage of Ketamine Sedation IM
1-1.5 mg/kg
74
Property of Ketamine
More lipid soluble Less protein bound Equally ionized Vs thiopental
75
Metabolism of Ketamine
Hepatic microsomal CP450
76
Metabolite of Ketamine
Nor-ketamine
77
Excretion of Ketamine
Excreted Renally | High hepatic clearance rate
78
Effect of Ketamine on CVS
Increase BP, HR and CO
79
Counter-indication for Ketamine
``` CAD Uncontrolled HTN CHF Aneurysms Space occupying intracranial lesion ```
80
Effect of Ketamine on Respiratory system
Minimally affect at induction dose Rapid/Repeated/Opioid coadmin causes apnea Potent bronchodilator (for asthmatic patient) Intact UAR
81
Effect of Ketamine on CNS
Increases CMRO2 Increases CBF Increases ICP Psychomimetic effect
82
What drugs does Ketamine potentiate
Non-depolarizing muscle relaxants
83
What two drugs mixture would form dangerous precipitation that would occlude IV line
Ketamine | Thiopental
84
MoA of BDZ
Enhance inhibitory NT | Increase conductance of Cl-
85
Receptor occupancy required to achieve anxiolysis, amnesia-sedation, hypnosis?
20% 30-50% 60%
86
Hydrophobic BDZ
Diazepam (Valium) | Lorazepam (Ativan)
87
Water soluble BDZ
Midazolam acidified (3.5) aqueous formulation minimal irritation Physiologic pH Change of physico-chemical property (lipid soluble)
88
BDZ specific receptor antagonist
Flumazenil
89
BDZ that are well absorbed from GIT + peak plasma level
Diazepam (1hr) | Lorazepam (2hr)
90
BDZ available in Intranasal, buccal and sublingual for children
Midazolam
91
Redistribution and Property of BDZ
Rapid redistribution | Can't match rapid onset and offset of thiopental
92
Lorazepam Vd, half life and duration
Vd limited by lower lipid solubility Shorter half life (15 hrs) Prolonged duration due to high receptor affinity
93
Midazolam Vd, half life and duration
Large Vd Small half life (2hrs) Shortest duration due to high hepatic extraction
94
Excretion of BDZ
Renal
95
Excretion of Midazolam in Renal failure patient
Prolonged sedation | Accumulation of conjugated metabolite (a-hydroxymidazolam)
96
Effect of BDZ on CVS
Minimal CVS depressant at induction dose Masked by laryngoscopic stimulation More marked in hypovolemic patient
97
Midazolam vs Diazepam (CVS)
Midazolam reduces BP, PVR more | Drug induced vagolysis by Midazolam
98
Effect of BDZ on Respiration
Depress ventilatory response to CO2 Apnea uncommon Depress swallowing reflex Reduce UAR
99
Effect of BDZ on CNS
Reduce CMRO2, CBF, ICP less than barbs Slower hypnosis Longer recovery Treatment of Status epilepticus
100
Drug that binds to CP450 and reduce diazepam metabolism
Cimetidine
101
Drug that inhibit midazolam metabolism and cause 2-3 increased intensity
Erythromycine
102
Displaces diazepam from protein-binding site and increase free drug concentration
Heparin
103
Metabolism and excretion of Flumazenil
Rapid metabolism in Liver | Excreted in urine as glucuronide conjugate

Basics of Anesthesia (4 decks)

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