Shannon-Induction Of Anesthesia For The CV Patient

Question 1

Patients with ___tension display an exaggerated response to induction agents and laryngoscopy —> more extreme ___tension to laryngeal stimulation, but also an increased ___tensive reaction to induction agents

Answer 1

Patients with hypertension display an exaggerated response to induction agents and laryngoscopy —> more extreme hypertension to laryngeal stimulation, but also an increased hypotensive reaction to induction agents

Question 2

Administering ___ or arterial ___ (i.e.: nitroprusside) can decrease the hyperdynamic sympathetic response to laryngoscopy

Answer 2

Administering beta blockers or arterial dilators (i.e.: nitroprusside) can decrease the hyperdynamic sympathetic response to laryngoscopy

Question 3

Use of ___ IV prior to intubation blunts the laryngeal reflex with intubation

Answer 3

Lidocaine IV

Question 4

Propofol MOA—direct ___ agonist

Answer 4

GABA-A

Question 5

Propofol induction dose ___-___ mg/kg in healthy patient; often much ___ (lower/higher) for CV patients

Answer 5

1-2 mg/kg in healthy patient; often much lower for CV patients

Question 6

Two compartment model for propofol distribution in the body—propofol rapidly distributes to ___ and highly ___ areas following IV injection in one circulation time; propofol rapidly redistributes into ___ compartments, circulates to less perfused areas, concentration ___ (increases/decreases) and ___ (slow/rapid) awakening occurs

Answer 6

Propofol rapidly distributes to brain and highly perfused areas following IV injection in one circulation time; propofol rapidly redistributes into peripheral compartments, circulates to less perfused areas, concentration decreases and rapid awakening occurs

Question 7

Propofol is rapidly metabolized in the ___

Answer 7

Liver

Question 8

Metabolism of propofol—extrahepatic metabolism sites (due to metabolism exceeding hepatic blood flow) results in tissue uptake of Propofol into areas including possibly the ___; need your patient to be ___ to metabolize this out!

Answer 8

Possibly the lungs; need your patient to be breathing to metabolize this out!

Question 9

Benefits of propofol—___ (slow/fast) onset; relatively ___ (short/long) half life; mild anti___ effects; very few serious ___ effects

Answer 9

Fast onset; relatively short half life; mild antiemetic effects; very few serious side effects

Question 10

Propofol CNS effects—___ (increases/decreases) cerebral blood flow, CMRO2

Answer 10

Decreases cerebral blood flow, CMRO2

Question 11

Propofol CV effects—___ (increases/decreases) BP, cardiac output, SVR; dose dependent ___ (increase/decrease) in BP within ___ minutes after induction

Answer 11

Decreases BP, cardiac output, SVR; dose dependent decrease in BP within 10 minutes after induction

Question 12

Etomidate MOA—___ agonist

Answer 12

GABA

Question 13

Etomidate induction dose = ___-___mg/kg

Answer 13

0.2-0.3 mg/kg

Question 14

Metabolism of etomidate = ___ hydrolysis

Answer 14

Ester hydrolysis—this is why the duration of action is so short

Question 15

Etomidate CV effects—hemodynamic ___ is achieved—___ (changes/no changes) in HR, pulmonary artery pressure, SVR, CO, and BP; acts as an alpha 2B adrenoreceptor agonist, which leads to a ___ (increase/decrease) in BP; no significant ___mias associated with etomidate

Answer 15

HD stability is achieved—no significant changes in HR, PA pressure, SVR, CO, and BP; acts as an alpha 2B adrenoreceptor agonist, which leads to an increase in BP; no significant arrhythmias associated with etomidate

Question 16

Etomidate CNS effects—dose dependent ___ (increase/decrease) in cerebral blood flow and CMRO2

Answer 16

Decrease

Question 17

Etomidate CNS effects—awakening occurs ___-___ minutes after administration

Answer 17

5-15 minutes

Question 18

Etomidate side effects—___ on injection; ___ and ___; thrombo___; myoclonia may resemble ___ like activity, but does not cause them; ___ suppression

Answer 18

Pain on injection; nausea and vomiting; thrombophlebitis; myoclonia may resemble seizure like activity, but does not cause seizures; adrenocortical suppression

Question 19

Etomidate side effects—adrenocortical suppression—inhibits 11B-___, which is essential in the body’s production of ___steroids and ___corticoids; the effects of a single etomidate dose can last for ___ hours; can cause increases in morbidity and mortality in patients on prior ___ therapy and/or patients in a ___ state

Answer 19

Inhibits 11B-hydroxylase, which is essential in the body’s production of corticosteroids and mineralocorticoids; the effects of a single etomidate dose can last for 72 hours; can cause increases in morbidity and mortality in patients on prior steroid therapy and/or patients in a septic state

Question 20

Ketamine MOA—noncompetitive ___ antagonist; inhibits ___; depressant effect on ___ nuclei, which blocks afferent signals of pain perception to the ___ and ___

Answer 20

Noncompetitive NMDA antagonist; inhibits glutamate; depressant effect on thalami nuclei, which blocks afferent signals of pain perception to the thalamus and cortex

Question 21

Ketamine causes a ___ state where the patient feels separated from the ___

Answer 21

Catatonic state where the patient feels separated from the environment

Question 22

Ketamine has ___ and ___ effects

Answer 22

Amnesic and analgesic effects

Question 23

Ketamine inhibits ___ factor alpha—may be responsible for its anti___ and anti___analgesic effects

Answer 23

Inhibits tumor necrosis factor alpha—may be responsible for its anti-inflammatory and antihyperanalgesic effects

Question 24

Metabolism of ketamine = ___ metabolizes ketamine into ___

Answer 24

Liver metabolizes ketamine into norketamine metabolite

Question 25

Norketamine has ___-___% the activity of ketamine

Answer 25

20-30%

Question 26

Ketamine CNS effects—airway reflexes maintain ___; ___ (increase/decrease) in salivary gland secretions; ___ (increase/decrease) in skeletal muscle tone; ___ (increase/decrease) in CBF, CMRO2, ICP; causes ___ waves on EEG

Answer 26

Airway reflexes maintain intact; increase in salivary gland secretions (give glycopyrrolate); increase in skeletal muscle tone (may have no purposeful movements); increase in CBF, CMRO2, ICP (give with a GABA agonist to counterract…i.e.: propofol, etomidate); causes theta waves on EEG

Question 27

Ketamine CV effects—indirect ___mimetic—use with caution in patients where an increase in ___ could be detrimental; ___ (increase/decrease) in myocardial contractility, may ___ (increase/decrease) myocardial oxygen consumption; ___ (increase/decrease) in BP, HR, CO, CVP

Answer 27

Indirect sympathomimetic—use with caution in patients where an increase in HR could be detrimental; increase in myocardial contractility, may increase myocardial oxygen consumption; increase in BP, HR, CO, CVP

Question 28

Benefits of ketamine—___ properties; potent ___

Answer 28

Analgesic properties; potent bronchodilator

Question 29

Side effects of ketamine—emergence ___; night___; ___ations

Answer 29

Emergence delirium, nightmares, hallucinations

Question 30

Caution using ketamine in patients with ___tension, ___ heart failure, and ___ ICP—the benefits of a stable hemodynamic profile may be outweighed by the potential for overstimulation of ___ release/___ (increase/decrease) in myocardial oxygen consumption

Answer 30

Caution using ketamine in patients with hypertension, congestive heart failure, and increased ICP—the benefits of a stable hemodynamic profile may be outweighed by the potential for overstimulation of catecholamine release/increase in myocardial oxygen consumption

Question 31

Ketamine is usually used in CV cases as an adjunct for multimodal analgesia, but not as a primary induction agent—T/F?

Answer 31

True

Question 32

Dexmedetomidine MOA—alpha 2 receptor ___ (agonist/antagonist)

Answer 32

Agonist

Question 33

Precedex dose—infusion loading dose of ___mcg/kg over ___ minutes; infusion ___-___ mcg/kg/hr

Answer 33

Loading dose of 1 mcg/kg over 10 minutes; infusion 0.2-1.5 mcg/kg/hr

Question 34

In CABG, precedex loading dose ___ (is/is not) used

Answer 34

Is not used—precedex is often just an adjunct sedative for time on bypass/transport to ICU at a drip rate of 0.4 mcg/kg/hr

Question 35

Precedex metabolism—extensive ___ metabolism

Answer 35

Hepatic

Question 36

Precedex CNS effects—dose-dependent sedation that resembles natural ___; ___ (does/does not) cause respiratory depression; ___ (does/does not) interfere with EEG monitoring; ___ (does/does not) change CMRO2; ___ (increase/decrease) in CBF d/t cerebral vaso___

Answer 36

Dose-dependent sedation that resembles natural sleep; does not cause respiratory depression; does not interfere with EEG monitoring; does not change CMRO2; decrease in CBF d/t cerebral vasoconstriction

Question 37

Precedex CV effects—___tension and ___cardia —> result of alpha 2 ___ and systemic vaso___; can occasionally see transient ___tension with loading dose/___ (low/high) maintenance rate (rare to see); no direct effect on myocardial ___

Answer 37

Hypotension and bradycardia —> result of alpha 2 stimulation and systemic vasodilation; can occasionally see transient hypertension with loading dose/high maintenance rate (rare to see); no direct effect on myocardial contractility

Question 38

Fentanyl MOA—___ agonist

Answer 38

Opioid

Question 39

Fentanyl dose—dependent on technique—standard ___-___ mcg/kg; can give doses up to ___ mcg/kg for induction

Answer 39

Standard 5-10 mcg/kg; can give doses up to 100 mcg/kg for induction

Question 40

Fentanyl metabolism—___ metabolism into ___ (active/inactive) metabolites

Answer 40

Hepatic metabolism into inactive metabolites

Question 41

Fentanyl CNS effects—___ and ___ properties; ___gesia; can cause ___ (increased/decreased) ICP if respiratory depression induced ___carbia occurs

Answer 41

Sedative and euphoric properties; analgesia; can cause increased ICP if respiratory depression induced hypercarbia occurs

Question 42

Fentanyl CV effects—___cardia; ___ effect on blood pressure; ___ (does/does not) affect myocardial contractility or baroreceptor function; these traits are why a high dose fentanyl induction can be useful for CABG patients where the need for rapid extubation postoperatively is not an issue—very stable cardiac profile

Answer 42

Bradycardia; no effect on BP; does not affect myocardial contractility or baroreceptor function

Question 43

Tabletop rescue drugs—phenylephrine MOA—direct acting alpha ___ agonist; virtually no ___ stimulation

Answer 43

Direct acting alpha 1 agonist; virtually no beta stimulation

Question 44

Phenylephrine—unopposed alpha stimulation can elicit a ___ reflex, causing reflex ___cardia with administration; useful for patients in which an increase in ___ is not desired, but an increase in ___ is necessary

Answer 44

Unopposed alpha stimulation can elicit a baroreceptor reflex, causing reflex bradycardia with administration; useful for patients in which an increase in heart rate is not desired, but an increase in BP is necessary

Question 45

Phenylephrine dose—syringes come in ___ mcg/ml; administer ___-___ mcg intervals to treat BP

Answer 45

Syringes come in 80 mcg/ml; administer 80-160 mcg intervals to treat BP

Question 46

Phenylephrine infusion—usually comes ___mg/___ml (peripheral strength concentration—a heavier concentration may be used via central line in ICU, so always check the bag)—start infusion at ___mcg/kg/min

Answer 46

Usually comes 20 mg/250 ml—start infusion at 0.02mcg/kg/min

Question 47

Tabletop rescue drugs—ephedrine MOA—synthetic non___ ___mimetic; stimulates ___ and ___ receptors directly; indirectly causes a release of endogenous ___

Answer 47

Synthetic noncatecholamine sympathomimetic; stimulates alpha and beta receptors directly; indirectly causes a release of endogenous catecholamines

Question 48

Ephedrine—causes dose dependent ___ (increase/decrease) in BP, cardiac output, HR, and SVR; acts in a similar manner to ___, only carries a ___ (shorter/longer) duration of action and ___ (does/does not) increase glucose levels like ___ can

Answer 48

Causes dose dependent increase in BP, cardiac output, HR, and SVR; acts in a similar manner to epi, only carries a longer duration of action and does not increase glucose levels like epi can

Question 49

Ephedrine dosing—comes in vials of ___mg/ml —> mix 1 ml of ephedrine with ___ ml of NS for a concentration of ___mg/ml; dose in ___-___mg increments IV

Answer 49

Comes in vials of 50 mg/ml —> mix 1 ml of ephedrine with 9 ml of NS for a concentration of 5 mg/ml; dose in 5-10 mg increments IV

Question 50

Ephedrine—can see ___phylaxis with subsequent dosing due to depletion of ___ stores

Answer 50

Can see tachyphylaxis (diminished response to successive doses of a drug) with subsequent dosing due to depletion of catecholamine stores

Question 51

You will see an increase in effectiveness of ephedrine over time—T/F?

Answer 51

False—you will see a decrease in effectiveness of ephedrine over time

Question 52

Tabletop rescue drugs—epinephrine—MOA—strong alpha ___ sympathomimetic catecholamine; dose dependent stimulation of ___ and ___ receptors

Answer 52

Strong alpha 1 sympathomimetic catecholamine; dose dependent stimulation of B1 and B2 receptors

Question 53

Epinephrine is used to treat patients in ___ states where there is poor tissue oxygen ___ and ___tension

Answer 53

Used to treat patients in shock states where there is poor tissue oxygen delivery and hypotension

Question 54

Epinephrine is used when patients are unresponsive to ___ (direct/indirect) acting sympathomimetics

Answer 54

Indirect acting sympathomimetics

Question 55

Epinephrine causes marked increase in ___tropy, heart ___, and conduction ___

Answer 55

Marked increase in inotropy, heart rate, and conduction velocity

Question 56

Epinephrine also increases myocardial oxygen ___

Answer 56

Consumption—need to watch your oxygen supply/demand balance

Question 57

Epi is rarely used in CV anesthesia outside of an arrest situation, but it is important to always have readily available for a patient who may be hypotensive and unresponsive to other tabletop rescue drugs—T/F?

Answer 57

True

Question 58

Epi comes in ___mg/ml vial doses

Answer 58

1 mg/ml vial

Question 59

Epi heavy concentration = ___mcg/ml

Answer 59

100 mcg/ml—mix 1 ml vial of epi in 9 ml of NS dilutent

Question 60

Epi lite concentration = ___mcg/ml

Answer 60

10 mcg/ml—mix 1 ml of epi “heavy” mixture in 9 ml of NS dilutent

Question 61

Tabletop rescue drugs—vasopressin—MOA—endogenous hormone produced in the ___, stored in the ___ pituitary gland; release is stimulated by ___ (increased/decreased) osmolality and ___volemia

Answer 61

Endogenous hormone produced in the hypothalamus, stored in the posterior pituitary gland; release is stimulated by increased osmolality and hypovolemia

Question 62

Vasopressin is also known as ___

Answer 62

ADH

Question 63

Vasopressin is a potent ___

Answer 63

Vasoconstrictor—second line usage after catecholamine vasopressors

Question 64

Vasopressin dosing—comes in vials ___ units/ml

Answer 64

20 units/ml

Mix 1 ml with 19 ml NS for a concentration of 1 unit/ml

Question 65

Vasopressin dosing—dose in increments of ___ unit at a time

Answer 65

1 unit at a time

Question 66

Vasopressin infusion dose—___units/min

Answer 66

0.04 units/min

Question 67

Vasopressin complications—___ ischemia, ___ (increased/decreased) cardiac output, digital ___, cardiac ___ at elevated doses

Answer 67

GI ischemia, decreased cardiac output, digital necrosis, cardiac arrest at elevated doses

Question 68

Tabletop rescue drugs—esmolol—MOA—beta ___ selective ___onist

Answer 68

Beta 1 selective antagonist

Question 69

Esmolol metabolism—___

Answer 69

Nonspecific plasma esterases

Question 70

Esmolol has an extremely ___ (slow/quick) onset and ___ (short/long) half-life

Answer 70

Extremely quick (2 min or less) onset and short half-life

^^^ this is d/t its metabolism but nonspecific plasma esterases

Question 71

Esmolol is useful to transiently treat ___ heart rate without carrying lasting effects that may cause subsequent ___ BP

Answer 71

Useful to transiently treat elevated heart rate without carrying lasting effects that may cause subsequent low BP

Question 72

Esmolol is often used alongside induction agents to prevent an increase in ___ during laryngoscopy

Answer 72

Prevent an increase in HR

Question 73

Esmolol concentration—___mg/ml in a ___ ml vial

Answer 73

10 mg/ml in a 10 ml vial (so total of 100 mg in the vial)

Question 74

Esmolol dosing—administer in increments of ___-___mg at a time

Answer 74

Administer in increments of 10-30 mg at a time

Question 75

Tabletop rescue drugs—nitroglycerin—MOA—direct vaso___, venous ___ (more/less than) arterial; caused by an induced release of vascular ___

Answer 75

Direct vasodilator, venous more than arterial; caused by an induced release of vascular nitric oxide

Question 76

Nitroglycerin causes veno___; used to treat elevated ___, prevent ___, and treat ___ during anesthesia

Answer 76

Venodilation; used to treat elevated BP, prevent angina, and treat ischemia during anesthesia

Question 77

Nitroglycerin decreases myocardial wall ___, cardiac ___ pressures, ___load, and myocardial ___ requirements

Answer 77

Decreases myocardial wall tension, cardiac filling pressures, preload, and myocardial oxygen requirements

Question 78

Nitroglycerin concentration—nitro “lite” vials obtained from pharmacy come ___mcg/ml in a ___ ml vial—dose in increments of ___ mcg at a time

Answer 78

40mcg/ml in a 10 ml vial (so 400 mcg in whole vial)—dose in increments of 40 mcg at a time

Question 79

Nitroglycerin infusion—UPMC Hamot infusion is 400 mcg/ml in a 250 ml bottle—infusion rate is typically started at ___mcg/min in a heart room

Answer 79

5 mcg/min

Question 80

Rescue infusions—norepinephrine MOA—potent alpha ___ sympathomimetic; little activity on ___ receptor at low doses (this increases some with higher doses)

Answer 80

Potent alpha 1 sympathomimetic; little activity on B1 receptor at low doses

Question 81

Norepinephrine infusion—causes ___ (increased/decreased) coronary artery perfusion pressure d/t increase in ___ BP; vaso___ causes a ___ (increase/decrease) in preload; ___ (increases/decreases) SVR

Answer 81

Causes increased coronary artery perfusion pressure d/t increase in diastolic BP; vasoconstriction causes an increase in preload; increases SVR

Question 82

___ is a first line choice for infusion when a vasopressor is indicated in a cardiac case

Answer 82

Norepinephrine

Question 83

Norepinephrine infusion concentration—___mg/250 ml; titration of infusion starting at ___ mcg/kg/min

Answer 83

16 mg/250 ml; titration of infusion starting at 0.02 mcg/kg/min

Question 84

Rescue infusions—dobutamine MOA—synthetic sympathomimetic ___; primarily a ___ agonist with some ___ effects

Answer 84

Synthetic sympathomimetic amine; primarily a beta 1 agonist with some B2 effects

Question 85

Dobutamine increases ___tropy, cardiac ___; BP may slightly increase or remain the same; decreases ___ d/t peripheral vaso___, decreases ___ pressure

Answer 85

Dobutamine increases inotropy, cardiac output; BP may slightly increase or remain the same; decreases SVR d/t peripheral vasodilation, decreases pulmonary artery pressure

Question 86

Dobutamine infusion dosing—___-___ mcg/kg/min

Answer 86

0.5-20 mcg/kg/min

Question 87

Rescue infusions—milrinone MOA—___ inhibitor; prevents the breakdown of ___

Answer 87

Phosphodiesterase 3 inhibitor; prevents the breakdown of cAMP

Question 88

Milrinone causes ___ (positive/negative) inotropic action and vaso___ without producing ___cardia

Answer 88

Positive inotropic action and vasodilation without producing tachycardia

Question 89

Vasodilation occurs within milrinone because in the smooth muscle, cAMP causes an efflux of ___ which results in ___ of the muscle

Answer 89

Efflux of calcium which results in relaxation of the muscle

Question 90

Milrinone ___ (increases/decreases) preload and afterload

Answer 90

Decreases

Question 91

Milrinone causes pulmonary vaso___

Answer 91

Vasodilation

Question 92

Milrinone improves ___ function; causes acceleration of ___ uptake by the sarcoplasmic reticulum

Answer 92

Improves LV function; causes acceleration of calcium uptake by the sarcoplasmic reticulum

Question 93

Milrinone is eliminated via the ___; caution in patients with ___ disease; buildup may cause ___

Answer 93

Via the kidneys; caution in patients with kidney disease; buildup may cause arrhythmias

Question 94

Milrinone infusion dosing—start infusion at ___mcg/min up to ___mcg/min

Answer 94

0.375 mcg/min up to 0.75 mcg/min