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NU 568

Exam 2 - Induction, Maintenance, and Emergence from Anesthesia

A successful anesthetic consists of what four characteristics? Anesthesia, analgesia, akinesis, hemodynamic stability
Why were the 4 stages of Guedel developed? To provide a better understanding of anesthesia for paraprofessionals during WWI
General anesthesia occurs in what 4 stages? Analgesia, excitement, surgical plan, anesthetic crisis
In Stage I of anesthesia, the patient (does/does not) experience pain and (can/cannot) communicate. does not, can
Stage II of anesthesia is called _________. Excitement
The patient in Stage II of anesthesia may experience ________ or become ________. Delirium, violent
What physiologic parameters are increased in Stage II? BP and RR
What are two dangers of Stage II anesthesia? Emesis, laryngospasm
How can the dangers of Stage II anesthesia be avoided? Premedication
What should be avoided in the Excitement stage of anesthesia? Noxious stimuli
Stimulation of the ____________ may break a laryngospasm. Larson's notch or laryngospasm notch
Which stage of anesthesia is referred to as the Stage of Disorientation? Stage I
What are the 3 planes of stage I anesthesia, as described by Artusio in 1954? 1)No amnesia or analgesia 2)complete amnesia, partial analgesia 3)complete amnesia and analgesia
What stage of anesthesia is characterized by irregular breathing and breath-holding? Stage II
What are two other names for Stage II anesthesia? Stage of Excitement or Stage of Delirium
Stage II of anesthesia occurs from ___________ to ___________. loss of consciousness, onset of automatic breathing
The 3rd stage of anesthesia is characterized by how many planes? 4
Which reflexes are present in the 1st plane of Stage 3 anesthesia? Lid, swallowing, airway
What is the state of respirations and chest movement in the 1st plane of Stage 3 anesthesia? Regular respirations w/good chest movement
Which reflexes are lost in the 2nd plane of Stage 3 anesthesia? Eyelid, laryngeal
Characterize the pupils and respiratory rate for the 2nd plane of Stage 3 anesthesia. Fixed pupils, regular RR
It is safe to begin surgery in what stage of Guedel's levels of anesthesia? Plane 2 of Stage 3
How is breathing affected in the 3rd plane of Stage 3 anesthesia? Shallow assisted breathing w/loss of chest and abdominal movement
What is the deepest plane of the 3rd stage of anesthesia and what is it characterized by? 4th plane is the deepest surgical anesthetic stage, characterized by apnea (no chest mvt., no diaphragmatic breathing)
In which stage of anesthesia does anesthetic crisis occur and what is it characterized by? Stage 4 - will see respiratory arrest and circulatory collapse
What is the most common means of induction in adults? Children? Adults=IV, children=inhalation
The anesthetic plan is influenced by what 3 factors? PMH, surgery, preference
When does preoxygenation and de-nitrogenation begin? Upon entering the OR
T/F: All stages of Guedel will be clearly identified as a patient progresses from one stage to the next. F - some may be brief, may not see some at all
What audible sound characterizes the Excitement stage of anesthesia? squeaky breathing or crowing
What are two different devices used to monitor heart and lung sounds during a case? esophageal and precordial stethoscopes
What two things must be done prior to giving any medications for induction? Preoxygenation and VS
Which reflex is lost in Stage II of anesthesia? Eyelash
When are manual ventilations assumed? After loss of lid reflex in Plane 2 of Stage 3 anesthesia
What are 3 NMBDs that are commonly used for induction? Succinylcholine, rocuronium, vecuronium
What is the dose, onset, and duration of succinylcholine? 1-1.5mg/kg, 45s, 3-5min
What is the dose, onset, and duration of rocuronium? 0.4-1.5mg/kg, 45s-3min, 25-30min
What is the dose, onset, and duration of vecuronium? 0.08-0.3mg/kg, 1-2min, 45min
What is scientific evidence of the readiness for intubation? TOF 0/4
After intubation, where should the anesthetist auscultate besides over the lungs? epigastrum
Who has ultimate responsibility for patient positioning? Anesthetist
What are the 4 common surgical positions for patients? Prone, supine, lateral, lithotomy
What position does the Shea headrest place the patient in? Sniffing position
When are the patient's eyes taped? Prior to masking
What are the most common nerve injuries related to patient positioning? Brachial, ulnar
What are lower body nerve injuries associated w/positioning in anesthesia? femoral, obturator, sciatic
What is more stimulating, intubation or incision? intubation
The maintenance plan for anesthesia should involve the consideration of what 4 types of medications? volatile anesthetics, IV anesthetics, narcotics, NMBDs
What is the 4-2-1 rule? Calculation for maintenance rate of IVF: 4cc for the 1st 10kg, 2cc for the next 10kg, 1cc for the remaining kg of bodyweight
Fluid loss could be encountered from either ________ or ________. blood, urine
What are two different anticholinergics given in anesthesia and what are their doses? Atropine 0.4mg, glycopyrrolate 0.2mg
What are the dose ranges for ephedrine and phenylephrine when given in anesthesia? ephedrine 5-10mg, phenylephrine 100-200mcg
What are the dose ranges for esmolol and labetalol when given in anesthesia? esmolol 5-10mg, labetalol 2.5-5mg
What is the purpose of a "foam nose"? Placed on the breathing circuit to maintain warmth and humidity
What are 5 methods to regulate body warmth in patients? Bair hugger, foam noses, fluid warmer, IV line placement under Bair hugger, heating the room
How many twitches in the TOF are required before the anesthetist is able to administer a NMB reversal agent? 1/4
What is the dose of neostigmine used for reversal of NMB? 0.035-0.07 mg/kg
What is the dose of glycopyrrolate that is used in conjunction with neostigmine? 7mcg/kg
THe ratio of neostigmine:glycopyrrolate usually ends up being ___________. 1:1
Identify two other adjunct medications in anesthesia and what are their respective dosages? Toradol 30mg IV/IM, zofran 4mg IV
What are 6 criteria for extubation? 1)Mac-Awake 2)adequate spontaneous ventilations 3)TV 7-10cc/kg 4)Sat >95% 5)NIF -20cmH20 6)follows commands
What are the 3 Commands criteria for extubation? Which one has the highest sensitivity for successful extubation? opens eyes, sustained head raise >5 sec, hand grasp and release; sustained head raise
What returns first upon emergence: diaphragmatic or peripheral function? diaphragmatic
Patients under anesthesia are most likely to become aware with exposure to what two types of statements? states of emotion and passion
Brachioplexus strain occurs at an angle above ________ degrees. 90
Upon transfer into the OR, when is a patient allowed to move to the operating table? when there is one person on each side and the bed is locked (confirmed verbally by anesthesia)
Airway equipment should be placed at __________. The head of the bed
Induction agents are given while the patient is (awake/asleep). Awake
The loss of lid reflex is checked (before/after) induction meds are given. after
The patient's eyes are taped closed (before/after) the loss of lid reflex. after
When is mask ventilation initiated? upon loss of lid reflex with eyes taped
What are three measures to improve suboptimal manual ventilations? 1)reposition patient's head 2)adjust operator arm position 3)place OPA/NPA
When is the NMBD injected? Once optimal manual ventilations have been achieved, along with appropriate preoxygenation/denitrogenation
What are signs that indicate readiness for intubation? 0/4 TOF, loss of eyelid reflex, fasciculations have ended (only w/succinylcholine)
What are two changes the anesthetist should make on the anesthesia machine after intubation? Lower FGF and turn on inhaled anesthetic
RSI is indicated in what 5 scenarios? Full stomach, pregnant, GERD, trauma, difficult airways
Succinylcholine is given (before/with/after) application of cricoid. with (applied simultaneously)
RSI (does/does not) include mask ventilation. does not
The different characteristics between barbiturates is related to differences in the carbons located at what two positions in the benzene ring? 2 and 5
How do barbiturates exert their effect? Interacting with the inhibitory GABA system
What is the primary inhibitory neurotransmitter in the CNS? GABA
Which channels do barbiturates affect and what do they cause? Affect chloride channels by causing increased duration of opening
What does the barbiturate effect on chloride channelse create and what does this result in? hyperpolarization, which results in inhibition of action potential
The keystone barbiturate is __________. sodium thiopental
Barbituric acid by itself (does/does not) have CNS effects. does not
How does barbituric obtain its sedative hypnotic effects? With changes to the number 2 and 5 carbons in its molecular structure
Which induction agent is a carboxylated imidazole containing compound? etomidate
What is unique about the solubility of etomidate? initially water soluble w/acidic pH, then has enhanced lipid solubility with molecular rearrangement to closed ring structure after injection
Etomidate is highly (ionized/non-ionized) at physiologic pH non-ionized
What percent of etomidate is non-ionized at physiologic pH? 99%
Etomidate has a (high/low) level of lipid solubility. high
Etomidate has a (high/low) level of protein binding. high
What is the cause for the initial and rapid awakening effect of etomidate? redistribution of active drug outside the CNS
What is the cause of prompt and full recovery from etomidate? rapid metabolism by hydrolysis
What are the enzymes responsible for etomidate metabolism? CYP and plasma esterase
What is the molecular portion of etomidate that undergoes metabolism and what is the byproduct? ethyl side chain; carboxylic acid
Which anesthetic agent is injected as an active drug? etomidate
Why does etomidate have a lower cumulative effect? not sequestered in adipose compartment
What is the dose for etomidate? 0.3mg/kg IV
What is the negative drawback to the use of etomidate? adrenocortical hypofunction
How does the use of opioids influence the side effects of etomidate? prevents hyperdynamic swings with DL
Are are post-op complications associated w/etomidate? PONV
T/F: Etomidate injection is not painful. False
Which induction agent has a significant relationship to PONV? etomidate
When does adrenal suppression due to etomidate take effect? How long can this effect last? 30min after injection; may last up to 24hr
Etomidate use may result in reduced levels of what two hormones? cortisol, aldosterone
How does etomidate inhibit steroidogenesis? blocks conversion of cholesterol to cortisol via hydroxylase inhibition
What is the trade name for etomidate? Amidate
The adrenal system is responsible for the ___________ response in sick patients (i.e. sepsis). stress
The use of etomidate may warrant supplementation with a __________. steroid
In what scenario will etomidate cause profound hypotension? hypovolemia
T/F: Intrarterial injection of etomidate has profound negative consequences. False
How does etomidate affect histamine response and renal/hepatic blood flow? It has no effect on histamine response and blood flow to the renal/hepatic systems
What physiologic function does etomidate suppress? How long does it take to recover from this? ventilation; 3-5min
How does etomidate influence CBF? To what percentage does it have this effect and what does it ultimately reduce? Decreases CBF by 35%, which decreases ICP
What effect does etomidate have on CMRO2? To what percentage does it have this effect? Decreases CMRO2 by 45%
What does etomidate increase in the CNS? Beta wave activity
Besides patients with sepsis, what other population should etomidate be used with caution in? patients w/focal epilepsy
How does etomidate affect patients w/non-focal epilepsy? capable of terminating status epilepticus
Which agent originally intended to be a mono-anesthetic agent? ketamine
Ketamine's dysphoric effects are least common with which patients? extremes of age
What are the different dosages for ketamine in mg/kg for each route of administration? Nasal 6-10, oral 6-10, IM 3-10, IV 0.5-2, rectal 10
What is the IV dose and onset for ketamine? 2mg/kg, onset=1min
What is the IM dose and onset for ketamine? 4mg/kg, onset=5min
The analgesic effects of ketamine mimics which narcotic? fentanyl
What are 4 physiologic effects of ketamine? amnesia, analgesia, immobility, CV upregulation
The molecular structure of ketamine contains a _________________ with two _______________. cyclohexanone ring, optical isomers
What are the two enantiomers in ketamine? (S-) left/(D+) right
What is the left enantiomer of ketamine and what are its effects? S-; intense analgesia, more rapid recovery, less emergence reactions
Which induction agent is prepared as a racemic mixture? ketamine
Ketamine is chemically similar to _________. PCP or phenylcyclidine
Describe ketamine's lipid and protein binding qualities. highly lipid soluble, low protein binding
Ketamine has brain concentrations _______ times greater than plasma concentrations. 5
Initial awakening from ketamine is related to _______________. redistribution to non-CNS compartments
What type of state does ketamine produce? dissociative state or cataleptic
Ketamine produces a dissociative state between what regions in the CNS? thalamus is dissociated from the cortex and limbic systems
Patients who have received ketamine appear to be ____________ but are _________ of their environment. awake, unaware
How does ketamine affect the eyes, corneal and light reflexes? eyes=open, corneal and light reflexes intact
Presence of a nystagmic gaze indicates that a patient (is/is not) ready for discharge home. is not
What are the skeletal muscle influences of ketamine prior to rendering akinesis? hypertonus w/involuntary movement
What does ketamine inhibit and where does this occur? glutamate at NMDA sites
What types of receptors does ketamine bind to? muscarinic and nicotinic cholinergic receptors, opioid receptors
What types of ion channels interact with ketamine? Na and Ca voltage dependent ion channels
Ketamine stimulates the (sympathetic/parasympathetic) nervous system. Sympathetic
What effect does ketamine have on HR and BP? increases both
What is ketamine's effect on oral and bronchial secretions? Causes excessive amounts of both types of secretions
Ketamine is metabolized by _________ enzymes to by the process of __________. CYP450, demethylation
What does the demethylation of ketamine yield? norketamine
Norketamine is an (active/inactive) metabolite. active
What is the level of potency of norketamine? 1/4 that of ketamine
Ketamine is believed to have an agonistic effect on what type of opioid receptors? mu
Norketamine is excreted in the (bile/urine). urine
How does ketamine influence CBF and ICP in vented patients? increases CBF w/o significant effect on ICP
What is ketamine's influence on CMRO2? no increase
Which anesthetic agent plays a neuroprotective role in cerebral ischemic situations? ketamine
Ketamine is a (positive/negative) inotrope. negative
How is the negative inotropic effect of ketamine mitigated? By its direct stimulation of the SNS
What are the CV effects of ketamine? Increased: HR, CO, myocardial oxygen demand, BP
What can be used to blunt the hyperdynamic responses to ketamine? Preadministration of sevoflurane, or periop use of short-acting betablocker
Ketamine may reverse dysrhythmias induced by what medication? digitalis
What is the effect on the HR when ketamine is used in conjuction with local anesthetics containing epi? dysrhythmias
What are the effects that ketamine has on the airway? upper airway reflexes remain intact; induces oral+bronchial secretions, bronchodilation; increased pulmonary vascular resistance w/subsequent increase in RV workload
Which anesthetic agent has been successfully used in status asthmaticus due to its potent bronchodilatory effects? ketamine
What medication should be given prior to admininstration of ketamine and why? glycopyrrolate in order to offset the cholinergic effects of ketamine
How does ketamine affect platelets? Causes reversible inhibition of platelet aggreation--similar to ASA
How does ketamine enhance muscle relaxation? interferes with calcium ion binding
Ketamine (inhibits/induces) plasma cholinesterase activity. inhibits
Aminophylline and theophylline are both ___________. bronchodilators
Patients who receive ketamine and are simultaneously taking aminophylline or theophylline are at increased risk for ___________ and _____________. Dysrhythmias, seizures
Ketamine reduces the the seizure and dysrhythmia thresholds for patients taking what two medications? aminophylline or theophylline
What is the incidence of psychogenic effects of ketamine? 5-30%
Psychogenic effects are most commonly seen by (women/men). women
How can the psychogenic effects of ketamine be reduced? Pre-administration of benzodiazepines or propofol
What is the classification of propofol? non-barbiturate sedative hypnotic anesthetic
Propofol's effects are primarily exerted on what receptors? GABA
The hyperpolarization of cells, as a result of propofol administration, occurs at the (pre/post) synaptic membrane. post
The metabolites of propofol are mostly (active/inactive). inactive
The metabolites of propofol are _______ soluble. water
What is suggestive about propofol's rate of clearance? Clearance exceeds hepatic blood flow, suggesting extra-hepatic sites of metabolism
What is the postulated extra-hepatic site of metabolism for propofol? pulmonary
A patient is rendered unconscious at what dose of propofol? 2mg/kg
Rapid and complete awakening from propofol occurs as a result of what mechanism? Redistribution away from the brain to less perfuse tissues
Propofol administration experiences a significant degree of what metabolic effect? 1st pass pulmonary uptake
Why is there a possible delay in the initial onset of effects for propofol? delay d/t 1st pass pulmonary uptake
Propofol (does/does not) cross into fetal circulation and is (slowly/rapidly) cleared in the neonate. does, rapidly
What are three reasons why propofol is the IV drug of choice for induction in anesthesia? Rapid: induction, emergence, return of neurologic function
Why do pediatric patients require a larger dose of propofol? Larger Vd, rapidly cleared
Propofol is found in colostrum for up to ____________ hours after admininstration. 8
How much should the dose of propofol be reduced in geriatric patients and why is it reduced? 25-50% due to smaller Vd and reduced clearance
Propofol may cause a significant degree of (hypotension/hypertension). hypotension
Patients in what CV state should not receive propofol for induction? hypotension, decreased CO, hypovolemia, shock
___________ and ___________ may greatly enhance the CV effects of propofol. Benzodiazepines, opioids
What is the dose of propofol for sedation? 25-100mcg/kg/min
What is the dose of propofol for TIVA? 100-300mcg/kg/min
High dosages and long-term use of propofol may lead to __________. propofol infusion syndrome
What are 5 signs of propofol infusion syndrome? Unexplained tachycardia, metabolic acidosis, myocardial dysfunction, possibly rhabdomyolysis, possibly green urine (crystallization)
T/F: Propofol infusion syndrome occurs only with prolonged use. False - Has been documented in short cases
Lab tests in a patient with propofol infusion syndrome may exhibit or indicate alterations in what 4 areas? blood pH (metabolic acidosis), lactate, rhabdomyolysis, renal function
Which anesthetic agent has been shown to have anti-emetic properties? propofol
How does propofol achieve its anti-emetic effects? directly depresses the emetic center in the medulla oblongata
Subtherapeutic doses of ___________ have been successful for the treatment of PONV in the PACU. propofol
In addition to anti-emetic properties, what other beneficial qualities does propofol possess? anti-convulsant
Which ion channels are inhibited by propofol? chloride ion channels
How does propofol affect CBF, ICP and CMRO2? decreases CBF, ICP, CMRO2
T/F: Propofol has no effect on CPP. Large doses may decrease MAP enough to alter CPP
Somatosensory evoked potentials (are/are not) significantly altered by propofol. are not
The use of propofol requires pre-administration of _______________ for at-risk patients. adequate volume
Which reflex is depressed by propofol? baroreceptor
Bradycardia and asystole associated with propofol possibly occurs due to ____________ and ___________. sympathetic attenuation, parasympathetic dominance
Propofol induced patients are (more/less) responsive to atropine. less
What beta agonist may need to be started to stabilize the patient induced with propofol? Isuprel
What is the generic name for Isuprel? isopreterenol
BONUS: Isopreterenol is structurally similar to what hormone? adrenaline
What effect does propofol have on vascular smooth muscle and why? Relaxes vascular smooth muscle d/t inhibition of SNS
Propofol causes decreased intracellular levels of _____________. Calcium
Propofol has (positive/negative) inotropic effects. negative
Propofol administered to the patient with __________ or __________ may result in a CV disaster. LV dysfunction, hypovolemia
What is the incidence of apnea in patients who receive propofol? 25-35%
Even without a bolus, propofol can blunt physiologic response to __________ and ________. Hypoxia, hypercarbia
What should always be administered in conjunction with propofol? O2
BONUS: Why do the lungs the exhibit pulmonary vasoconstriction in hypoxic states? To shunt blood flow to better-ventilated areas of the lungs
Hypoxic pulmonary vasoconstriction is (altered/intact) with propofol administration. intact
T/F: It is okay to safely use 1 vial of propofol between multiple patients as long as the rubber stopper is disinfected with isopropyl alcohol. False - vials are single patient use only
Unused portions of propofol should be discarded within _________ hours after opening. 6
How often should propofol tubing be replaced? Q12h
It is safest to follow (departmental/manufacturer) guidelines concerning propofol administration and outdating. departmental
Created by: philip.truong