Pharmacology (Orientation) Flashcards
(539 cards)
1
Q
Pharmacokinetics
A
a quantitative study of the absorption, distribution, metabolism, and excretion of injected and inhaled drugs and their metabolites “What the body does to the drug”
2
Q
Pharmacodynamics
A
study of the intrinsic sensitivity or responsiveness of receptors to a drug and the mechanics by which these occur “What does the drug do to the body”
3
Q
Tolerance
A
hyporeactive owing to chronic exposure to a drug
Cross-tolerance is common b/w drugs that produce similar pharmacologic effects (alcohol & inhaled anesthetics)
4
Q
Tachyphylaxis
A
tolerance that develops acutely; reflects cellular tolerance
5
Q
Additive
A
two drugs (inhaled anesthetics) interact to produce an effect (MAC) equal to algebraic summation
6
Q
Synergetic
A
two drugs interact to produce an effect greater than algebraic summation
7
Q
Agonist
A
a drug that activates a receptor by binding the receptor
8
Q
Partial agonist
A
a drug that binds weakly to the receptor and produces minimal pharmacological effect
9
Q
Antagonist
A
a drug that bind to a receptor w/out activating the receptor, and at the same time, prevents an agonist from stimulating the receptor
10
Q
Competitive
A
11
Q
Non-Competitive
A
12
Q
2-Compartment Model
A
A drug is injected intravenously into the central compartment and subsequently distributes to the peripheral compartment, only to return eventually to the central compartment where clearance from the body occurs
Any residual drug present in the peripheral compartment at the time of repeat intravenous injection will result in a cumulative effect
12
Q
Elimination Half-Time-
A
the time necessary for the plasma concentration to decrease by 50% during the elimination phase (Only reflects elimination in the central compartment)
13
Q
Context-Sensitive Half-Time-
A
time necessary for the plasma concentration to decrease 50% after terminating an infusion of a particular duration (Describes multicompartment pharmacokinetics )
14
Q
Oral Drug Administration
A
Undergoes liver first-pass , which decreases the amount of the drug being systemically circulated. Small intestine is the principal sight of injection
Oral Transmucosal Administration (Sublingual, Buccal, nasal mucosal )- No Hepatic first-pass
15
Q
Transdermal administration
A
(Sub-Q, IM, IV)- Rapid and precise drug delivery best achieved w/ IV administration, Hepatic first-pass does not occur (Vs. Enteral- Thru alimentary tract)
16
Q
Vd (Volume of Distribution)-
A
a mathematical expression (dose of IV drug administered/resulting plasma concentration) that depicts the distribution characteristics of a drug in the body
* Binding to plasma proteins and poor lipid solubility limit passage of a drug to tissues, thus maintaining a nigh concentration in the plasma and a small calculate Vd
* A lipid-soluble drug that is highly concentrated in tissues w/ a resulting low plasma concentration will have a high calculated Vd
17
Q
Clearance
A
the volume of plasma cleared of drug by renal excretion and/or metabolism in the liver or other organs
18
Q
Systemic Clearance
A
Permanent removal of a drug
19
Q
Intercompartmental Clearance
A
movement of drug from one compartment to another (Main cause of termination of effect for drugs)
20
Q
Cytochrome p450
A
Responsible for the biotransformation of endogenous compounds, pharmacological agents, and environmental xenobiotics
* Propofol, Fentanyl, midazolam, morphine, lidocaine
21
Q
Drug Concentration
A
Given as a weight (Mass)/ volume. Defines how much you have (Propofol conc.= 10mg/mL)
22
Q
Drug Dose
A
Given as a mass of drug per unit mass of the patient (Defines how much you give (Adult induction of propofol is 2 mg/kg
23
Q
Red Man Syndrome
A
an infusion-related reaction peculiar to vancomycin. It typically consists of pruritus, an erythematous rash that involves the face, neck, and upper torso. Less frequently, hypotension and angioedema can occur
24
Hyperalgesia
More sensitive to a pain stimulus
* Work in a longer-acting opioid when stopping a remifentanil infusion
25
Suboxone
mix of Buprenorphine and Naloxone used to treat heroin and methadone addiction
26
Scopolamine Patch
Motion sickness patch, helps with PONV and works up to 3 days
Works Quickly
Will dilate eyes if you touch the patch and then touch your eyes
Can cause dry mouth and dry eyes
Anticholinergic
27
Type and Screen
Screen patient’s blood to make sure we have that product available. (Screening takes a long time) (About an hour)
28
Type and Cross
Crossmatched with the units available and ready (About 20 mins after we have a type and screen)
Anticipate blood loss, just start with a type and screen, it can be over 2 hours during busy times.
Sometimes pre-op nurse doesn't have time to send type and screen, use 2 pink vials.
One will print, the other put a patient label on there.
29
Dilute Phenylephrine
2.5cc+7.5 NS Phenylephrine
30
Dilute Ephedrine
1+9 ephedrine
31
Dilute Dilaudid
(1+9)=10 =200 mcg/mL
32
Norepinephrine Dilution
2cc concentrate +8cc NS
33
SYstemic Drug Redistribution
As the plasma concentration of a drug decreases below than in highly perfused tissues (liver, heart, brain, lungs), the drug leaves these tissues to be redistributed to less well-perfused sites, such as skeletal muscles and fat
34
Biotransformation
substance changing from one chemical to another
35
Tissue Metabolism
Cleared in tissues or plasma via ester hydrolysis (Sux, Esmolol, Remifentanil) (Succinylcholine, Esmolol, Remifentanil)
36
Renal Clearance
Kidneys eliminate drugs through filtration by the glomerulus
Steroidal musle relaxants (Vecuronium/Rocuronium)
37
Distribution Clearance
Removal of drug from one compartment to another (blood to tissue)
38
Protein Binding
Protein-bound drugs are not "bioavailable" to exert their effect
39
The Half-Life of a drug is increased with
a large Vd and decreased with a small Vd. Can't be metabolized or cleared if it’s not in plasma or reaching the liver
40
Plasma concentration of a drug with a long half-life can still fall rapidly as
It redistributes from a vessel-rich compartment (Muscle/fat/synovial fluid)
41
Half Life is not a predictor of
Drug effect
42
Narcotic Bag at UC Anschutz includes
* 2 Propofol 20 vials
* Ephedrine 10 cc (5mcg/mL)
* 2mL vials of Fentanyl (x2)
1 vial of Dilaudid (2mg/mL)*Diluted)
43
Quick reversal of Benzodiazepines can result in
Propofol can help with this!
44
1% Lidocaine concentration
10mg/mL
45
2% Lidocaine Concentration
2mg/mL
46
.5% Lidocaine Concentration
5mg/mL
47
.25% Lidocaine COncentration
2.5mg/mL
48
1:1000 Epi concentration
1g Epi in 1000mL of solution
or 1mg/mL
49
Morphine Opioid index
Morpine =1
Dilaudid =10
Fentanyl =100
Remi= 100-300
Sufentanil 500-1000
Alfentanil= 10-20x
Meperidine= 1/10
50
What are the active Metabolites of Morphine
M6G, M3G
51
What drug is dosed on total body weight instead of ideal body weight
Succinylcholine
52
Properties of drugs with a high volume of distribution (Vd)
-Higher tissue concentration than in plasma
-Relatively lipid soluble
-Distributed intracellularly
-Not efficiently removed by hemodialysis
53
Role of metabolism
convert a pharmacologically active, lipid-soluble drug into water soluble, pharmacologically inactive metabolites
54
Types of IV Access
Peripheral
Central Line
Picc Line
Tunneled Central Line (Hickman/ Broviac cath (No Reservoir)
Mediport/Portacath (reservoir)
55
Gauge of an IV
DIameter of the lumen
inversely proportional (Bigger number, smaller the diameter)
56
Supplies needed to start an IV
IV Bag
Tourniquet
Gloves
Alcohol wipes/Chloraprep
IV Catheter
Tegaderm
Tape
4x4 Gauze
Local**
57
Peripheral IV complications
Infection
- Phlebitis
-Sepsis
-Infiltration
58
Phlebitis
Inflammation of a vein that the body tries to naturally repair by clotting (Thrombosis)
This is bad if it travels to the heart
59
Sepsis
Systemic bloodstream infection
60
Infiltration
Blown Vein
Cannula situated outside the vein (extravasation), leaking fluids/meds in the tissue , causing necrosis, cellulitis, and pain
61
Central Line
Subclavian
Femoral
Internal Jugular
infuses large volumes quickly , remains for longer periods than an PIV
better for long-term pressor infusions
62
Central Line Complications
Pneumothorax (Punctured Lung)
Hematoma, arrhythmia (tip of cath touches the heart wall , causing electrical conduction to change)
63
Tunneled Central Line (Hickman or Broviac)
Plastic cath with cuff (balloon) near exit site. Does not have reservoir
Large diameter (13fr)
Multiple lumens for simultaneous drug administration
64
Mediport
Has a small reservoir subcutaneous (Under Skin)
Increased pt. comfort, accessed when needed, no tubing exiting skin
Decreased infection rates
65
Total Body Water
Avg
66
Two major fluid compartments
ICF-Intracellular Fluid
ECF- Extracellular Fluid
67
ECF (Extracellular Fluid)
Intravascular- in the bloodstream (mostly plasma)
PLUS
Interstitial- all fluid outside cells and outside vascular system
68
Rule of Approximate Thirds
69
Normal Sodium (Na+ ) values
140
70
Normal Potassium(K+) Values
4.5
71
Normal Magnesium(Mg) Value
1.2
72
Normal Calcium(Ca2+) Value
2.4
73
Normal Chloride (Cl-) Value
100
74
Normal Bicarb (HCO3) Values
25
75
Normal Phosphorus (P) Values
1.2
76
Capillary Hydrostatic Pressure
Pressure drives fluid out of capillary (filtration) and occurs highest at arteriolar end of capillary and lowest at venular end (think feeding tissues)
77
Edema
Occurs when fluid moves into insterstitial space faster than it can be drained by the lymphatic system
78
Why is edema harmful
it increases the distance between capillary and tissue cells and that reduces the effectiveness of meeting metabolic needs
79
Causes of edema
hypervolemia
Decreased renal fxn
cardiac failure
80
INterstitial fluid pressure
Pressure determined by interstitial fluid volume and by the compliance of the tissue
81
Plasma colloid osmotic Pressure
Because the capillary barrier is permeable to ions, the osmotic pressure within the capillary is principally determined by plasma proteins (oncotic) that are relatively impermeable
82
Fxn of plasma colloid osmotic pressure
Draws from interstitial space back to capillaries
83
Molarity
Moles per liter
84
Molality
Moles per Kg
85
Normal Osmolarity
285-290 mOsm/L around 273 mOsm/L
86
NS (Normal Saline)
Slightly hyperosmolar
at 308 mOsm/L
87
LR (Lactated Ringers)
Slightly hypoosmolar at 283 mOsm/L
88
Plasmalyte
Isoosmolar (Seen mostly in cardiac trauma, and large blood loss cases)
89
Crystalloids
Used to replace maintenance of fluid requirement, deficits, evaporate losses, and third space losses
90
Fluid that is cheap, readily leave intravascular system and go to the interstitial space
Crystalloids
91
Normal Saline
Has same NaCL balance as the body
92
Large volumes of NaCl can cause
Dilutional hyperchloremic acidosis b/c of its high Cl- concentration
93
Normal saline uses
Renal disease patients (No K+)
Giving PRBCs (No Calcium)
94
Lactated Ringers (LR)
Most physiological solution when large volumes are needed
95
LR Osmolarity
SLightly hypotonic, 100mL free water/L
96
The liver metabolizes lactate into
Bicarbonate
97
5% Dextrose in Water (D5W)
Dextrose in metabolized leaving a large volume of free water
Used for pts on Sodium (Na+) Restriction
98
Percentages in IV Fluids and medications represent
Number of grams per mL of dilutent %g/mL
99
IV half-life of crystalloids
20-30 min
100
IV Half-Life of COlloids
3-6 hours
101
Colloids replace blood loss at what ratio
1:1
102
Colloids
Used to replace blood loss or restore intravascular volume
It’s a solution of proteins & sugars with high molecular weight….large enough to exert oncotic pressure
103
Types of Colloids
Albumin
Hetastarch & Pentastarch
104
Hetastarch and Pentastarch
derived from plasma proteins or synthetic glucose polymers
105
Albumin
derived from human blood (5% or 25%)
106
Which type of fluid replacement type is a plasma volume expander?
Colloids
107
Which is more expensive? Colloids or crystalloids?
Colloids
108
Hetastarch
Derived from the starch amylopectin, given as 6% solution in 0.9%NS or LR
Effect: is plasma volume expansion
Elimination: by kidney, degraded by circulating enzyme amylase
Half life IV: Hetastarch 25 hours
109
Hetastarch/ Pentastarch contraindications
pts with known sensitivity to hydroxyethyl starch, with a coagulopathy, with Congestive heart failure (CHF) where vol overload is a problem or with pts with oliguria or anuria (little urine or no urine)
110
Use for Albumin
Used to increase intravascular volume for decreased blood pressure
111
Complications of fluid therapy
Peripheral Edema
Pulmonary Edema
Increased Intracranial Pressure (ICP)
Coagulopathies
Colloid allergy
112
Fluid losses are greater when
- vomiting, diarrhea, bowel prep
- fever
- hyperventilation
- loss of skin integrity (burns)
113
Insensible fluid loss
No electrolytes involved like in sweat.
Evaporative water loss from the respiratory tract.
-Insensible daily loss is 400 mL in adult
Evaporation of H2O that crosses skin via diffusion.
-Insensible loss from respiration is 400 mL/day
114
Redistribution (3rd Spacing)
Shifting of fluid from vasculature to interstitial space
Traumatized tissue becomes edematous
3rd space loss is isotonic- replaces with LR
115
3rd Spacing is caused by
caused by tissue edema (ie: surgical trauma pulls fluid from interstitial space)
116
Blood Loss calculation
Volume in suction minus irrigation used
Volume on drapes
Volume on the floor
Volume in surgical sponges
117
If there is substantial bloood loss intraoperatively, what should occur?
Serial monitoring of the patient's hematocrit is warranted
118
4x4 sponge holds how much blood?
10mL
119
Raytec sponge will hold how much blood?
10-20mL
120
Laps
will hold 100mL of blood fully soaked
121
Normal urine output in the OR
1-2mL/kg/hr
122
Oligouria
Reduced urine production
<.5mL/kg/hr
May be a sign of dehydration, urinary obstruction, renal failure
123
Anuria
No urine output
124
H&H consists of
Hemoglobin and Hematocrit
125
Normal Hemoglobin levels
10-13
126
Normal Hematocrit Values
Men: 42-52
Women: 37-47
127
How do Hemoglobin and Hematocrit relate?
Hematocrit = 3 x Hgb
128
EBV Equation
kg x BV (mL/kg)
129
Blood volume for neonates
Premature 95 mL/kg
Full-term 85mL/kg
130
Blood Volume for Infants
80mL/kg
131
Blood volume for adults
Male 75mL/kg
Female 65mL/kg
132
ABL
Allowable Blood Loss
133
ABL Equation
ABL = EBV x (Hct i – Hct f)/
Hct i
Wt = Weight in kg
EBV = Estimated blood volume (mL)
Hct i = Hematocrit initial (use in decimal value) Ie: Hct = 45%, use 0.45
Hct f = Hematocrit final
134
Loss of skin causes
hypothermia, increased water loss, increases risk for infection and sepsis
135
Minimal tissue trauma additional fluid replacement
2-4mL/kg
136
Moderate tissue trauma additional fluid replacement
4-6 mL/kg
137
Severe tissue trauma addional fluid replacement
6-8mL/kg
138
Midazolam/Versed Drug class
Benzodiazepine
139
Midazolam uses
Anxiolysis (anterograde) amnesia, sedation, andiconvulsant
140
Midazolam concentration
1mg/mL
141
Midazolam MOA
GABA Agonist- activates inhibitory neurotransmitter in the brain
142
Midazolam usual adult bolus
1-2mg
143
Caution for Midazolam
Synergy w/ Opioids
Liver Biotransformation into end products that are renally secreted (renal failure leads to prolonged effect)
Elderly require less or none at all because of risk of delirium
144
Benzodiazepine Reversal Drug
Flumazenil
145
Flumazenil use
reversing the sedative and respiratory depression of a benzodiazepine overdose
146
Cautions on Flumazenil
Can cause siezures in patients with rapid benziodiazepine reversal
147
Adult dose for flumazenil (reversal)
.2mg over 5 seconds
Repeat .1mg q 1min to a total of 1mg
148
Fentanyl Concentration
50mcg/mL
149
Fentanyl Dose
1-2mcg/kg
150
Fentanyl Infusion Dose
1-2 mcg/kg/hr
151
Routes of administration for Fentanyl
PO, IV, Transdermal patch
152
Duration of Action for Fentanyl
30-60 minutes
153
How is fentanyl metabolized?
75% is metabolized by pulmonary uptake, which helps it last longer
154
How strong is fentanyl compared to morphine?
100x stronger than morphine
155
Which opioid is preferred over Morphine because it causes less histamine release?
Dilaudid
156
Dilaudid Concentration
1-2mg/mL
157
Dilaudid dose
01-.05mg/kg
158
Bolus dose for Dilaudid
0.2mg/dose titrated to respiratory rate
159
Routes of administration for Dilaudid
IV, PO
160
Peak effect of Dilaudid
10-20min
161
Duration of Dilaudid
3-4 Hours
162
How strong is Dilaudid in comparison to Morphine?
10x stronger
163
Dilaudid Metabolism and Clearance
H3G Liver biotransformation, can be neurotoxic (active metabolite)
Renal Clearance
164
Meperidine Trade Name
Demerol
165
Use for Meperidine/Demerol
Post-Op Shivering
166
Dose for Meperidine
12.5mg
May be repeated once
Post-Op Shivering 25mg IV
167
Time to peak effect of Meperidine
15min
168
Duration of Action for Meperidine
2-3 hours
169
Meperidine strength compared to Morphine?
1/10x
170
Meperidine Metabolism/ Clearance
Liver biotransformation into norMeperidine, an active metabolite
Renal Excretion of metabolite can lead to CNS Excitability
171
Remifentanil Trade Name
Ultiva
172
Remifentanil MOA
Potent Mu agonist mainly used as an infusion due to its rapid onset and metabolism
173
Remifentanil Dose
Titrated infusion .5-1mcg/kg/min
174
Bolus Dose for Remifentanil
1-2mcg/Kg (not as common)
175
Duration of Action for Remifentanil
3-4 Minutes (stays consistent regardless of duration of infusion)
176
Remifentanil metabolism
Broken down by non-specific tissue esterases into remifentanil acid
Renal Excretion
177
What drug is used to reverse Opioids
Naloxone/ Narcan
178
Narcan/ Naloxone use
Reversing sedative and respiratory depression of a relative opiod overdose
179
Considerations when administering Narcan/ Naloxone
It may wear off before the opioid effects do and may require re-dosing
May cause flash pulmonary edema
180
Onset of Naloxone/Narcan
2 min
181
Duration of Action of Narcan
30 Min
182
Typical adult dose of Narcan
0.04mg IV (40 mcg)
Needs to be dilutedS
183
Stock concentration of Naloxone/Narcan
.4mg/mL *Needs to be diluted
184
Mechanism of Action for Local Anesthetics
Block nerve transmission by blocking Na+ Channels inside the cell, inhibiting Na+ influx and propagation of an action potential (Nerve impulse)
185
Ionic movement in Local anesthetic Mechanism of action
LAs must be uncharged to pass thru the cell membrane, but then need to be charged to bind to Na+ channel inside the cell
186
Onset of Local Anesthetics can be affected by
Decreasing pKa Speeds onset
187
How does chloroprocaine work so fast?
Results from high concentration used despite its high pKa
188
What is the fastest acting Local Anesthetic
Chloroprocaine, used in emergency C-sections
189
How does Lipid solubility relate to potency in Local Anesthetics?
Lipid Solubility increases potency
190
Local Anesthetics in order of potency
Tetracaine-> Bupivicaine-> Lidocaine-> MepivicaineA
191
Amide Local Anesthetics
Have an I in them
LIdocaine
MepIvicaine
BupIvicaine
RopIvicaine
192
Ester Local Anesthetics
Procaine
Chloroprocaine
Tetracaine
Cocaine
Benzocaine
193
How are amide local anesthetics metabolized
Liver biotransformation
194
How are Ester local anesthetics metabolized?
Pseudocholinesterases
195
Lidocaine infiltration dose
5mg/kg without Epi
7mg/kg with epi
196
Lidocaine use in intubation
Used to blunt airway reflexes during induction at 1mg/kg given IV
197
What local anesthetic can be given IV?
Lidocaine
198
Can Bupivicaine be delivered Intravenously
NO,
can lead to Local Anesthetic Toxxicity (LAST) and cardiac arrest
199
Routes of administration for Bupivicaine
Skin infiltration, neuraxial
200
Neuraxial anesthesia
Spinal
Epidurals
201
Max dose of Bupivicaine
2.5mg/Kg
3 mg/Kg w epi
202
Propofol MOA
GABA Mediated
203
Propofol Dose
1.5-2.5mg/kg
204
Propofol Concentration
10mg/mL
205
Propofol Infusion Dose
25-200 mg/kg/min
206
Considerations for Propofol
Can cause bacterial growth due to lipid emulsion. Change tubing after 6 hours
207
Propofol effects
Decrease BP, Cardiac Contractility
Respiratory depressant causing apnea
Cerebral Protectant (Lower oxygen demand in the brain)
Causes burning on IV Push (Give Lidocaine first)
208
Propofol metabolism and clearance
Liver metabolism
Renal Clearance
209
Etomidate Cardiac Effects
Cardiostable
Can be used for induction for patients with cardiomyopathy
210
Etomidate MOA
Reticular activating system depression
211
Concentration of Etomidate
2mg/mL
212
Dose of Etomidate
.1-.4mg/kg (Adult)
213
Effects of Etomidate
Burns when injected
PONV
Myoclonus
Causes Adrenal Suppression
214
Etomidate Metabolism/Clearance
Liver Enzymes and plasma Esterases (Not as rapid as propofol)
215
Ketamine Drug Class
Phencyclidine (PCP)
216
Ketamine MOA
NMDA Antagonist (Dissociation of Thalmic and Limbic systems)
217
Ketamine Concentration
10, 50, 100mg/mL
218
Induction dose for Ketamine (IV)
1-2.5mg/kg
219
IM induction dose for Ketamine
4-8mg/kg
220
Uses for ketamine
Induction, Analgesia, Amnesia
221
Ketamine effect on the heart
Doesn't depress HR and BP, good for Cardiomyopathy
222
Benefit of using Ketamine as an analgesic vs. Opioids
Doens't depress respiratory rate
Great for analgesia and avoiding opioid induced side effects/Respiratory depression
223
What medication can be given IM for induction?
Ketamine (4-8mg/kg)
224
Side effects of Ketamine
Increase RR, HR, BP
Increase in Salivation
Causes Delirium/hallucinations
225
What adjunct drugs can we use for Ketamine's side effects (Delirium/hallucinations + excess salivation)?
Midazolam for delirium
Glycopyrrolate for excess secretions
226
Absorption time for Ketamine when given IM
10-15mins
227
Ketamine Metabolism/ Clearance
Biotransformed into active metabolite Norketamine
Renal Excretion- with large doses can be prolonged in ESRD
228
Volatile Anesthetics currently used
Nitrous Oxide
Sevoflurane
Desflurane
Isoflurane
229
Which volatile anesthetic can be used for induction
Sevoflurane
230
Why can't desflurane be used for gas induction?
It is an airway irritant
231
Why can't Isoflurane be used for gas induction?
It takes too long to take effectWh
232
Why can't Nitrous oxide be used for gas induction?
It is impossible to achieve 1 MAC with nitrous oxide
233
How do volatile anesthetics work?
Causes general anesthesia (Amnesia, Anesthesia, Akinesia) at varying concentrations in the blood/lungs
234
How is volatile anesthetic effectiveness measured
MAC- Minimum alveolar concentration
235
Define MAC-1
The concentration of gas that suppresses movement in 50% of surgical patients
236
How does MAC change with age?
Decreases by 6% every decade after 40 years
237
What factors can increase MAC
Acute Amphetamine use
Cocaine Use
Ephedrine
Ethanol (Chronic use)
hypernatremia
Hyperthermia
238
MAC is highest at what age?
6 months
239
Factors that decrease MAC
barbituates
Benzodiazepines
Ketamine
Ethanol (Acute use)
Local Anesthetics
Opioids
Lithium
Verapimil
Elderly age
Anemia
Pregnancy
240
How are volatile anesthetics metabolized?
Absorbed via the lungs and eliminated via the lungs
241
Anesthetic effect of volatile anesthetics is determined by
The partial pressure of the brain (Pbr)
Hard to measure clinically, so we use the lungs as a surrogate
242
With volatile anesthetics, when does induction occur?
When FA=Fi
243
Blood Gas Partition Coefficient
The ratio of gas dissolved in the blood versus what does not dissolve is a unique property of each gas and determines onset/uptake of the gas
Agents with low solubility in the blood saturate the blood quicker. Any additional molecules of gas after saturation are then transferred to the brain
244
Blood Gas Partition Coefficient for Nitrous Oxide
0.47
245
MAC % for Nitrous Oxide
104%
246
Blood Gas Partition Coefficient for Desflurane
0.45
247
Desflurane MAC%
6
248
Sevoflurane Blood Gas Partition Coefficient
.65
249
Sevoflurane MAC%
2
250
Isoflurane MAC%
1.4
251
Isoflurane Blood Gas Patition Coefficient
1.4
252
Volatile anesthetic effects on BP
Decreases with increasing concentration of volatiles
253
Volatile Anesthetic effects on HR
HR incrases with increasing concentrations of volatiles (Desflurane above 1 MAC is most clinically relevant)
254
Volatile Anesthetic effects on Respiratory rate
Increase RR and lower tidal volumes in varying concentrations
255
What type of drug is a bronchodilator?
Volatile Anesthetics
256
What drugs can be used during bronchospasms or asthma attacks
Volatile Anesthetics, specifically Sevoflurane
257
Volatile Anesthetic effects on Cerebral Bloodflow (CBF)
Increased Cerebral Bloodflow and can decrease Cerebral metabolic rate
258
Volatile Anesthetic effects on Neuromonitoring
Can cause Decreased SSEP and MEP firings
259
Sevoflurane Induction
Slower than Desflurane, faster than Isoflurane
Intermediate emergence time
260
Sevoflurane concerns
Can be metabolized and broken down into a neprotoxic byproduct called compound A at low fresh gas flows
261
Desflurane onset time
Fastest of the volatile anesthetics
Also has fast emergence
262
Desflurane Concerns
Cost
Airway Irritant
Pungent smell
Caution in patients with Asthma/ COPD
Can lead to Carbon Monoxide poisoning in older CO2 Absorbers
263
Isoflurane characteristics
Slow onset time, cannot be used for inhalation induction
Pungent and can be an airway irritant
Cheap
264
Nitrous Oxide Onset speed
Fast
265
Nitrous Oxide Concerns
PONV
Can fill enclosed airspaces
Avoid in COPD/ Lap procedures/inner ear/ LMA/ Intracranial procedures/ Pneumothorax
266
How does Nitrous Oxide affect Vitamin Metabolism?
Can affect Vitamin B12 Metabolism
267
Four Stages of Anesthesia
Analgesia
Excitation
Surgical Anesthesia
Coma
268
Stage 1 of Anesthesia
Analgesia
The patient becomes sedated
269
Stage 2 of Anesthesia
Excitation
There is an increase in heart rate and blood pressure
270
Stage 3 of Anesthesia
HR and BP begin to return to normal
Patient is deep enough for surgery to begin
271
Stage 4 of Anesthesia
Coma
The patient's vital signs collapse
272
Uses for Neuromuscular blockers
Chemically paralyze skeletal muscle at the NMJ
273
NdMB MOA
Blocking nicotinic acetylcholine receptors
274
D-NMBA MOA
Causing a prolonged depolarization
275
WHich neuromuscular blocking agent is short acting
Succinylcholine
276
What is a long-acting non-depolarizing Neuromuscular Blocking agent
Pancuronium
277
Succinylcholine MOA
prolonged depolarization of NMJ (inactivating Na+ channels)
278
Succinylcholine dose
1-2mg/kg, can also be given IM
279
DOA for Succinylcholine
Rapid onset 30-60 seconds, hydrolyzed in 5-10 minutes
280
Metabolism of Succinylcholine
Hydrolyzed by pseudocholinesterases in plasma prior to reaching the NMJ
281
Situations where SUccinylcholine is preferred
RSI
Full stomach
Difficult Airway
282
Side effects of Succinylcholine
Cardiac Dysrhythmias
Bradycardia, junctional rhythm, Sinus arrest
Hyperkalemia
Myalgia
Sore Muscles
Myoblobinemia
Increased intragastric/intracranial/
intraocular pressure
283
Contraindications of Succinylcholine
Muscular Dystrophy
Burn Patients
Muscle Atrophy patients
284
Pseudocholinesterase defficiency
285
Pseudocholinesterase
a glycoprotein enzyme produced by the livr
286
Dibucaine
An Amide Local Anesthetic used to test for Pseudocholinesterase deficiency
When administered IV, capable of inhibting the plasma cholinesterase enzyme
287
In normal patients, dibucaine will inhibit
80% of enzyme activity which corresponds to dibucaine number of 80
288
Homozygous typical pseudocholinesterase
Normal Dibucaine 70-80
289
Heterozygous atypical Pseudocholinesterase
1/480 incidence
Lengthended response 50-100%
Dibucaine number 50-60
290
Homozygous atypical pseudocholinesterase
1/3200
Dibucaine Number 20-30
Prolonged 4-8 hours
291
Which genotype for pseudocholinesterase will have a prolonged effect for 4-8 hours and require a transfer to the ICU?
Homozygous Atypical
Dibucaine number 20-30
292
Rocuronium COncentration
10mg/mL
293
Intubation dose of ROcuronium
.6-1.2 mg/kg
294
Onset of Rocuronium
1-3 minutes
295
DOA of ROcuronium
30-80 mins
296
Clearance of Rocuronium
Hepatic Metabolism and Renal excretion
297
Cautions when using ROcuronium
ESRD patients
Reduce in chronic kidney disease liver
298
Doses of 1.2mg/kg of Rocuronium can achieve what
Muscle paralysis in <1min, making it useful for RSI when Sux is contraindicated
299
Vecuronium concentration
1mg/mL
from a 10mg Powder
300
intubation dose of Vecuronium
.08-.12 mg/kg
301
Vecuronium onset
3-5 mins
302
Vecuronium DOA
20-35
303
Vecuronium Clearance
Hepatic Metabolism and renal excretion
304
Cisatracurium COncentration
2mg/mL
305
Cisatracurium intubation dose
.1-.2 mg/kg
306
ONset of Cisatracurium
3-5min
307
DOA of Cisatracurium
20-35 min
308
Clearance of Cisatracurium
Organ dependent form of elimination by being broken down by Hoffman Elimination in plasma
309
What patient population is especially good for Cisatracurium use? WHy?
Due to its unique clearance, cisatracurium is generally used in severe renal or liver failure patients
310
What neuromuscular blockers cannot be reversed with Sugammadex?
Succinylcholine
Cisatracurium
311
Train of 4 Monitoring
Peripheral stimulation of 4 successive electrical impulses from a nerve stimulator
Each twitch causes a release of ACh at the NMJ
312
If there is no paralysis, how will the TOF monitor reflect?
4/4 (4 twitches) with no fade
313
If the patient is fully paralyzed, how will the TOF Monitor reflect?
0/4 (No Twitches)
314
The degree of twitches indicates the degree of
Paralysis
this will guide the dose of the reversal agent
315
How do neuromuscular blocking reversals work?
Unbinding the NMB from the Ach Receptor (Sugammadex) or indirectly by outcompeting the NMB from the Ach receptor by flooding the NMJ w/ Ach (Neostigmine)
316
Common TO4 MOnitoring Sites
Ulnar Nerve
Facial Nerve
Posterior Tibial nerve
317
TOF Ratio
>=0.9 as measured by the Adductor POlicis Muscle
318
Neostigmine MOA
Anticholinesterase
Inhibits breakdown of Ach in the NmJ, allowing a higher amount of Ach to compete with NMBA at the NMJ
319
Dose of Neostigmine
.04-.08mg/kg with a max dose of 5mg (Lower doses preferred w/ lower TOF ratios)
320
DOA of Neostigmine
10-30 min for full effect since it is an inhibiting enzyme and indirectly increasing Ach levels
321
Side effects of Neostigmine
SLUDGE
It increases ACh unspecifically by inhibiting AChE, it causes parasympathetic activation as well
322
Since Neostigmine produces a parasympathetic activation as a side effect, what must we do?
Give an antimuscarinic (Glycopyrrolate) as an adjunct
323
SLUDGE
Salivation
Lacrimation
Urination
Defecation
GI Upset
Emesis
Bradycardia/Bronchospasm
324
Sugammadex
Directly antagonizes steroid NMB (Roc/Vec) by encapsulating the drug
325
How fast does sugammadex work?
2-3 minutes with very few side effects
326
327
Concerns with Sugammadex
THe bound drug is renally cleared and may not be removed with dialysis, so use with caution in ESRD Patients
328
Sugammadex dose in 4/4 TOF
1 mg/kg
329
Sugammadex dose in 3/4
2 mg/kg
330
Sugammadex dose in 2/4
2 mg/kg
331
Sugammadex dose in 1/4
4mg/kg
332
Sugammadex dose in 0 TO4 w/ 4/4 PTC
4mg/kg
333
Sugammadex dose in 0 TO4 with NO PTC
16 mg/kg
334
PONV
`POst-Operative Nausea and Vomiting
335
Risks for PONv
Female
Nonsmoker
History of PONV
History of MOtion sickness
<50yo
336
What do we use/do that can cause PONV
VOlatile Anesthetics
Use of N2O
Duration of Anesthesia
Type of Surgery
Use of Opioids intraoperatively
post-op opioids
337
Dexamethasone typical adult dose
4mg
338
Dexamethasone contraindications
Diabetic Patients
339
Side effects of dexamethasone
Can have an intense burning in apocrine glands after IV Push (armpits and genitals burn like crazy)
340
Ondansetron MOA
5-HT3 receptor
341
What is Zofran best for
Preventing vomiting better than preventing nausea
342
ZOfran Dose
4mg IV or 8mg PO as ODT
343
Zofran concerns
Can Cause QT Prologations
344
Nausea is beleived to be regulated by
The CTZ (Chemoreceptor Trigger zone) in the brainstem through several different receptors
345
Benadryl Drug class
H1, H2, M1 Antagonist
346
DOse of Benadryl
1mg/kg (Generally 12.5 mg for anti-emetic)
347
Cautions with Benadryl
Can cause sedation
348
ONset of Benadryl
<30 mins
349
Uses for benadryl
Anti-emetic
Anaphylaxis
Puritis
350
Reglan MOA/Drug class
D1 Antagonist, cholinergic Agonist
351
Dose for Reglan
5-10mg
352
Properites of Reglan
Anti-Emetic
Promotes GI MOtility via cholinergic agonism
353
Onset of Reglan
<30 Min
354
Contraindications of Reglan
Avoid in Parkinson's
GI Obstruction
355
Droperidol MOA
Dopamine Antagonist
356
Dose of Droperidol
.625 mcg for anti-emetic
357
Concerns with Droperidol
avoid in people with Prolonged QT syndrome , Parkinson's
358
Onset time of Droperidol
3-10mins (Given Prior to wakeup)
359
Phenergan(Promethazine) MOA/
H1, M1, D1 Antagonist
360
Dose for Phenergan
6.25mg for anti-emetic
361
Phenergan COncerns
May cause sedation
Avoid in Parkinsons
362
ONset of Phenergan
3-5 mins
363
Use of Phenergan
Used as a rescue anti-Emetic in PACU due to fast onset
364
Main goal of anesthesia
TO augment and control the autonomic nervous system during surgery
365
Sympathetic Nervous system
Fight or Flight
366
Parasympathetic Nervous system
Rest and digest
367
Sympathetic nervous system characteristics
SHort pre-ganglionic fibers and long post-ganglionic fibers
368
Parasympathetic Nervous system characteristics
Long Preganglionic fibers with short post-ganglionic fibers
369
Alpha 1 Agonists (Adrenergic)
Vasoconstrictors
INcreases BP
Increased SVR
370
B1 Agonists (Adrenergic)
Increases HR
Contractility
(Chronotropy/inotropy)
371
B2 Agonist (Adrenergic)
Bronchodilators
372
The CHolinergic (PNS) Response
Decrease HR
Decrease BP
Bronchoconstriction
373
4 Factors that affect BP
HR
PReload
Contractility
Afterload
374
COx SVR
=BP
375
(HRx SV) x SVR
=BP
376
(HR x (LVEDV-LESV)))x SVR
=BP
377
LVEDV
Preload
378
LVESV
Contractility of the heart
379
HRx (Preload-Contractility)) x Afterload
=BP
380
Vasoactive Medications typically
Increase or Decrease HR, BP, and SVR
381
What is the goal for Anesthesia when maintaining BP/HR
Maintaining values and output within 20% of pre-operative values
382
Epinephrine Drug class
Catechloamine/ Sympathiomimetic
383
Epinephrine Use
Increase HR/ BP
Treat Anaphylaxis
Treat Bronchospasm
Used in Cardiac Arrest
Can be aerosolized to treat airway edema and croup
384
Croup
disease that causes swelling in the airways and problems breathing. Children with croup often have a high-pitched “creaking” or whistling sound when breathing in. This is called stridor
385
EPinephrine MOA
Alpha 1
Alpha 2
Beta 1
Beta 2
AGONIST
386
Concentration of Epinephrine
1mg/mL
387
Dose of Epinephrine
.01-.05 mcg/kg/min (Titrate to effect)
388
Small Dose of Epi Receptor Effects
1-2mcg/min
Beta 2 Agonist
389
Medium Dose of Epi
4mcg/min
Beta 1 Agonist
390
Large Dose of Epi
10-20 mcg/min
Alpha and Beta Agonist
391
Epinephrine as an Alpha 1 Receptor Agonist
Increased Vasoconstriction
Increased Peripheral Vascular Resistance
Decreased Mucosal Edema
392
Epinephrine as an Alpha 2 Receptor Agonist
Decrease Insulin Release
Decreased Norepinephrine Release
393
Epinephrine as a Beta 1 Agonist
Increased Inotropy
Increased Chronotropy
394
Epinephrine as a Beta 2 Agonist
Increased Bronchodilation
Increased Vasodilation
Increased Glycogenesis
Decreased Mediator Release
395
Norepinephrine Drug Class
Catechloamine/ Sympathiomimetics
396
MOA of Levophed/ Norepinephrine
Potent Alpha 1 Agonist with enough Beta 1 to prevent reflex bradycardia/ Maintain HR and Cardiac Output
397
MOA of Levophed/ Norepinephrine
Considered an Alpha 1 agonist with some B1 effects
398
Concentration of Levophed/ Norepinephrine
1 mg/mL
399
Dose of Norepinephrine
.01-.5mcg/kg/min (Titrate to effect)
400
What is the general use of Levophed/ Norepinephrine?
Generally given centrally in septic/ Vasoplegic shock patients
401
Concerns with Levophed
High doses peripherally can cause distal tissue necrosis/ ischemia from the vasoconstriction
402
Ephedrine Drug glass
Synthetic Non-Catechloamine/ Sympathiomimetics
403
Uses for Ephedrine
Increases HR
Increases Contractility
Increases BP
404
Concentration of Ephedrine
5-10mg/mL
405
Dose of Ephedrine
5-20mg
406
MOA of Ephedrine
Stimulates release of catechloamines in pre-junctional nerve terminals and binds to alpha and beta receptors on the post-junctional membrane
407
Onset of Ephedrine
Onset is relatively short
but longer compared to catechloamines due to its indirect mechanism of action
408
Tachyphylaxis
Tolerance where subsequent doses are not effective, as catechloamine stores are depleted pre-junctionally
409
Ephedrine indirectly releases what catechloamine
Norepinephrine
410
Concerns with Ephedrine
Tachyphylaxis
Persistent blockade of adrenergic receptors
Depletion of Norepi storage
411
Phenylephrine class
Synthetic non-catechloamine/Sympathiomimetics
412
Phenylephrine MOA
Stimulates the Alpha 1 receptor (Increase BP/Afterload)
413
Use for Phenylephrine
Vasoconstrictor
(increase BP, can be used as a nasal decongestant )
414
Bolus DOse of Phenylephrine
500-100mcg or more depending on BP response
415
Infusion Dose of Phenylephrine
.1-1 mcg/kg/min
416
Cautions with Phenylephrine
Increases afterload, making it undesirable with certain cardiomyopathies/ Valvular Problems
Also causes Reflex Bradycardia
417
What is our first choice agent when BP is low and Cardiac output is thought to be adequate
Phenylephrine
418
Albuterol Drug Class
Beta 2 Agonist
419
Albuterol Drug type
Bronchodilator
Causes smooth muscle relaxation in the bronchioles - adminstered via an inhaler or nebulizer
420
Albuterol Uses
Treat restrictive airway disease (COPD), asthma, emphysema, bronchitis (Bronchospasm)
421
What is an alternate use for Albuterol
Can also be used to slow premature labor
422
Vasopressin
An endogenous form of ADH released from the posterior pituitary gland and works on V1 and V2 Receptors
423
Vasopressin works on which receptors?
V1
V2
424
Vasopressin V1 MOA
Increases BP via increased SVR without theoretically reducing cardiac output
425
Vasopressin V2 MOA
Increased blood Volume by increasing water reabsorption from the kidney (ADH Action)
426
Vasopressin Metabolism
Hepatic/Renal
427
Vasopressin Half-Life
10-20 Mins
428
Bolus Dose of Vasopressin
.5-1.0 unit bolus for refractory Hypotension
429
Septic Shock Dose for Vasopressin
.02-.1 Units/min for septic shock infusion
430
Cautions for Vasopressin
Gastric hypoperfusion from potent vasoconstriction: Bowel Ischemia/ Raised Liver enzymes/ reduced platelet count
431
Higher doses of Vasopressin may cause
Myocardial Ischemia
Hyponatremia
Cutaneous Necrosis from extravasation
432
Hyponatremia
Low Sodium Values
433
Effect of Hyponatremia
Seizures, delirium
434
Indications for Vasopressin
Vasoplegic/ Septic Shock
Refractory Hypotension
+ Lisinopril administration
435
What patient population would benefit from Vasopressin over other pressors?
Pulmonary Hypertension patients could benefit from Vasopressin since there is alpha receptors in the pulmonary artery , but not V1 receptors
436
How can vasopressin be substituted for epineprine in a code/ Cardiac Arrest?
Single dose of 40 units IV may replace a round of 1mg of epi in a code
437
Anti-Hypertensives
Metoprolol
Labetalol
Esmolol
Hydralazine (Vasodilator)
Calcium Channel Blocker ( Nicardipine)
438
Beta Blockers MOA
Work by blocking B1 receptors (Decrease HR, Inotropy, and BP)
439
Overdosing a beta blocker can result in
Bradycardia
CHF in cardiomyopathy
440
Which Beta Blocker has a higher affect on BP than HR?
Labetalol
441
Labetalol affects what receptors?
Alpha 1
Beta 1
Beta 2
442
Labetalol Use
Lowe HR and BP (Better at lowering BP)
443
Concetration of Labetalol
5mg/mL
444
Bolus dose of Labetalol
5mg boluses titrated to effect
445
Esmolol Drug class
Cardioselective B1 Blocker
446
Esmolol Use
Short-Term Decrease in HR
447
Esmolol Concentration
10mg/mL in 10mL
448
Dose of Esmolol
Titrated boluses usually
449
Esmolol Duration of Action
Short DOA
1-3 minutes due to elimination by plasma esterases
450
Metoprolol Drug Class
Cardioselective B1 Blocker
451
Uses for Metoprolol
Decrease HR/BP
452
Concentration of Metoprolol
1mg/mL
453
Dose of Metoprolol
1-2mg
454
Metoprolol DOA
Longer DOA and often used for chronic HTN
455
Hydralazine Class
Vasodilator
456
Hydralazine use
HTN-Great for hypertensive patient who may have some underlying cardiomyopathy where decreasing inotropy/ HR may be contraindicated
457
Concentration of Hydralazine
20mg in 1 mL
458
Dose of Hydralazine
5mg 10mg titrated to effect
459
Onset of Hydralazine
15-20mins
460
Duration of Hydralazine
6-8 hours
461
Cautions of Hydralazine
Prinicpal arterial dilator and long onset time, so easy to overdose and cause hypotension
462
Two types of calcium channel blockers
Dihdydropyridines
Non-dihydropiridines
463
Dihydropyridines
Ca2+ channel blockers
Primary vasodilators (Don't decrease HR)
464
Non-Dihydropyridines
Ca2+ Channel blockers
More cardioselective and decrease HR and causes vasodilation
465
Nicardipine Uses
Lowers BP without causing an increase in ICP
466
Non-dihydropyridine drugs
Diltiazem, verapamil
467
What cases would probaby benefit from Nicardipine?
Neuro cases or those that require tight BP control
468
Dihydropyridine drugs
Nicardipine, Clevidopine, nifedipine, amlodipine
469
Nicardipine infusion dose
5-15mg/hr
470
Nicardipine blous dose
100-200mcg
471
Nicardipine Onset
1-5 mins
472
Nicardipine Concentration
.2mg/mL
473
Anticholinergic Drugs
Glycopyrrolate, Atropine, Scopolamine
474
MOA of Anticholinergics
Antagonizes the sympathetic NS via blockade of muscarinic Ach receptors
475
Uses for Anticholinergics
Bradycardia Treatment
Used in conjunction with acylcholinesterase inhibitors to block parasympathetic activation (Neostigmine)
Bronchodilation
PONV prevention
476
Atropine Uses
Bradycardia response
Vagal Response
NMB Reversal
477
Concentration of Atropine
.4mg/mL
478
Atropine bradycardia dose
.4-.6 mg (up to 3mg)
479
Which drug works faster? Glycopyrrolate or Atropine
Atropine
480
Which Anticholinergic drug crosses the bloodbrain barrier?
Atropine
481
Glycopyrrolate uses
Antisialagogue
NMB Reversal
Bradycardia
482
Concentration of Glycopyrrolate
.2mg/mL
483
Premed antisialagogue dose of Glycopyrrolate
.2mg IM
484
Glycopyrrolate reversal dose
.2mg per 1mg Neostigmine
485
Glycopyrrolate Bradycardia dose
.2mg or more
486
Scopolamine Uses
Antiemetic
delivered via transdermal patch behind the ear
487
Precedex trade name
Dexmedetomidine
488
Side effects from Scopolamine crossing the BBB
Blurred vision
Dry mouth and throat
Slight sedative/ delirium in elderly patients
489
Precedex MOA
Alpha 2 agonist (Binds presynaptic ganglion inhibiting Norepi release)
490
Use for Precedex
Sedation/ anxiolysis without respiratory depression and able to respond to commands, analgesia, sedation for fiberoptic intubations, smooth emergence
491
Concentration of Precedex
Diluted typically to 4mcg/kg over 5-15 minutes followed by infusion dose of .2-1mcg/kg/hr
492
Precedex Metabolism
Liver
493
Side effects of Precedex
Large boluses can cause HTN, but more frequently we see sympthiolysis (Bradycardia/ hypotension) with infusion
494
Precedex is great for
Sedation with minimal respiratory depression and the patient will respond to commands . Also a great analgesic and is used frequently for multimodal pain modalities
495
Describe the negative Feedback Loop of Precedex
Precedex blocks presynaptic Alpha 2 receptors in a negative feedback loop, resulting in the suppression of Norepinephrine release
496
5 A's of Anesthesia
Amnesia
Anesthesia
Analgesia
Anxiolysis
Akinesa
497
Amnesic
Causes Memory loss for an event/time period
498
ASA 1
Normal Healthy Patient
499
ASA 2
Patient with mild systemic disease
500
ASA 3
Patient with severe systemic disease that is not a constant threat to life
501
ASA 4
Patient with severe systemic disease that is a constant threat to life
502
ASA 5
Moribund patient not expected to survive with or without surgery
503
ASA 6
Organ donor, Brain Death, DCD
504
STOP BANG Questions
Snoring
Tirdedness
Observed Apnea
Pressure
BMI >35kgm^-2
Age over 50
Neck Circumference >40
Gender (Male)
505
High risk for OSAS (STOP-BANG)
>=3 positive responses
506
Low risk for OSAS (Stop-Bang)
<3 positive Responses
507
Contraindications for Nasopharyngeal Airway
Skull Fractures
Anticoagulants
Actively bleeding nose (Epitaxis)
508
Contraindications for Oropharyngeal Airway
Gag Reflex intact
Foreign body obstructing the airway
Mouth Surgery
509
What is the concern when a patient is under sedation without a protected airway?
Aspiration
510
LMA/SGA Absolute Contraindications
Trauma
Non-Fasted Patients (RSI-GETA)
Bowel Obstruction
Emergency Surgery
Delayed Gastric Emptying
511
LMA/SGA Relative Contraindications
Major Abdominal surgery
Pregnancy >14 weeks
Prone Positioning
Airway Surgery
Laparoscopic Surgery
Obesity (BMI>30)
Decreased Lung Compliance (W PIP>20cm H2O)
Altered Mental Status
512
Why shouldn't we let the vent pressure (w/ LMA) or bag mask pressure exceed 20cm H2O
Because the esophageal sphincter is opened at pressures higher than 20 cmH20
513
How long do we wait after pushing Rocuronium for ET tube placement
3 Minutes
Start the NIBP, bag mask if not RSI
514
What do we set the vent to after we have placed the ETT?
PCV-VG
515
Most common blade sizes for direct laryngoscopy
Miller 2
MAC 3
516
Where does the MAC Blade sit inside the patient's mouth/airway?
Inside the Vallecula
517
Where does the miller blade sit in the patient's airway/mouth?
Elevates the epiglottis
518
What can we do to improve our view during direct laryngoscopy?
Cricoid pressure
Video Scope
try a different blade
Try getting in a better sniff position
elevate the head of the bed for better visualization
519
What classification system is used for views obtained by direct laryngoscopy?
Cormack-Lehane
520
Predictors of difficult bag mask Ventilation
BOOTS
Moans
Beard, Old , Obese, toothless, snores
Mask seal
obstruction
Age
No teeth
Stiff lungs
521
In theory, how long can we bag mask a patient?
Forever
522
DAMMITS
Drugs
Airway
Machine
Monitors
IVs
Tube
Suction
523
Drugs used for a typical GETA case
Versed
Fentanyl
Lidocaine
Propofol
Sux
Roc
Ephedrine/Phenylephrine
524
What airway supplies will we need for each ETT Placement?
Stylet
Eye Tape
TUbe Tape
Laryngoscopes+ blades
Bite Block
Oral/Nasal Airway
525
What's included in Standard ASA Monitors
Temp
EKG (3 or more leads)
Pulse Oximeter
NIBP
EtCO2
526
Malampatti I
Complete visualization of the soft palate
527
Malampatti II
Complete visualization of the uvula
528
Malampatti Class III
Visualization of only the base of the vulva
529
Malampatti Class IV
Soft palate is not visible at all
530
Planned procedure during which the patient undergoes local + sedation and analgesia. Patient is typically able to breathe on their own and respond to commands
MAC- Monitored Anesthesia Care
531
Unlike IV drugs ___ are absorbed via the lungs and eliminated via the lungs
Volatile Anesthetics
532
When is anesthesia achieved with volatile anesthetics
When inaled= ExhaledT
533
TIVA-
Total IV Anesthesia
534
Increased Risk of PONV
Female
Type of Surgery
Dehydration
Smoking Decreases PONV Risk
Pre-Op Anxiety
535
In Volatile Anesthetics, how does Cardiac Output affect induction
Slow cardiac output increases speed of induction
536
Induction is achieved when
Fa=Fi (Inspired)
537
538
