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IV Induction Agents
| Question | Answer |
|---|---|
| Barbiturates are what type of solution? | Highly Alkaline |
| What property do barbituric solutions have? | Bacteriostatic |
| BONUS: What does bacteriostatic mean? | A chemical that inhibits bacterial growth. |
| Barbiturates are weak (acids/bases)? | Acids |
| What can happen to barbiturates if they are mixed with acidic compounds? | Precipitation |
| BONUS: What does precipitation mean? | The formation of a solid from a solution. |
| What are three examples of acidic compounds that cause precipitation with barbiturates? | Opioids/Catecholamines/NMBAs |
| What are other receptors affected by barbiturates? | Glutamate/Adenosine/Neuronal Nicotinic AcH receptors |
| Barbiturates have greater CNS access if they are (ionized/non-ionized)? | Non-ionized |
| The non-ionized form of barbiturates are favored by high or low pH? Describe what that environment would be called. | Low pH/Acidosis Environment |
| The ionized form of barbiturates are favored by high or low pH? Describe what that environment would be called. | High pH/Alkalosis Environment |
| BONUS: What part of California is Sonia Mae from? | San Fernando Valley |
| Barbiturates depress which neurological network? Ultimately, what receptors are potentiated by this? | Reticular Activating System (RAS) / GABA |
| (High/Low) doses of barbiturates cause an excitatory phenomena. | Low |
| (High/Low) doses of barbiturates cause EEG burst suppression. | High |
| Which waves are replaced with EEG burst suppression of barbiturates? Which waves are formed? | Beta & Alpha waves are replaced by Delta & Theta waves. |
| What do Delta & Theta waves lead to on an EEG reading? | Isoelectric Flat Line |
| Name two Barbiturates used and the induction dose for each. | Thiopental 3-5 mg/kg IV Methohexital 1-1.5 mg/kg IV |
| What is the other name for Thiopental? | Pentothal |
| What is the other name for Methohexital? | Brevital |
| Which barbiturates is used for ECT and why? | Methohexital (Brevital) - It's methyl radical group on the #5 carbon atom enhances convulsant activity. |
| How long after giving a barbiturate will unconsciousness occur? | 30-60 seconds |
| Which NMBA is given with barbiturates for RSI? | Succinylcholine (Anectine) |
| What is important to remember with giving barbiturates and NMBAs? | Make sure you adequately flush the IV line to reduce precipitation. |
| How are barbiturates metabolized? | Phase 1 metabolism with hepatic microsomal enzymes. |
| Where are the metabolites excreted? | Bile/Urine |
| Are barbiturate metabolites (active/inactive)? | Inactive |
| T/F: All barbiturates are excreted in urine as unchanged drug? Explain | False - Phenobarbital is the only one unchanged in urine. |
| T/F: Barbiturates are CYP450 enzyme inducers? | True |
| What enzyme is promoted in barbiturate oxidative metabolism? What does this enzyme form? | Aminolevulinic Acid Synthetase / Porphyrin |
| What is porphyrin important for? | Heme Synthesis |
| What patients should avoid barbiturates? | Acute Intermittent Porphyria |
| How is ventilation effected by barbiturates? | Depressed via reduction in tidal volume and respiratory rate. |
| How is the CV system effected by barbiturates and by what physiological system? | Peripheral vasodilation and venous pooling by depressed sympathetic outflow from depression of the medullary vasomotor center. Tachycardia occurs as a compensatory mechanism. |
| BONUS: What food can Meghan not eat? | Food containing gluten. |
| What is the emulsion of Propofol made? | 10% soybean / 2.25% glycerol / 1.2% egg lecithin |
| T/F: Egg lecithin is made from the whites of an egg? | False - Yoke |
| How many hours after opening Propofol? should the unused portion be discarded? IV line changed after how many hours? | 6 hours / 12 hours |
| T/F: Propofol is a chiral compound? | False |
| What is the dose of Propofol and how long will it take to accomplish unconsciousness? | 1.5-2.5 mg/kg IV / 30-60 seconds |
| Why is Lidocaine given before Propofol? | To inhibit pain caused from proposal infusion. |
| T/F: Propofol and Lidocaine can be safely administered together in one syringe? | False - It can cause oil drops and increase the risk of developing PE. |
| Propofol works on which receptors? | GABA |
| Describe the relationship between Propofol and the effects of amnesia/analgesia/anticonvulsant properties. | Propofol HAS anticonvulsant and amnestic properties. Propofol DOES NOT have analgesic properties. |
| How does Propofol effect CBF/ICP/CMRO2? | Decreases all 3. |
| What other pressure does Propofol decrease? | Intraocular pressure. |
| Although Propofol can produce burst suppression on EEG, what phenomena can occur, and how is it observed? | Excitatory / Twitching |
| T/F: There is no evidence of impaired elimination of Propofol for patients with obesity, cirrhosis, and renal dysfunction. | True |
| BONUS: What is Drew Smith's favorite food chain in Philadelphia? | Chipotle |
| What patients benefit from Propofol? | Patients with asthma/wheezing. It produces bronchodilation. |
| What reflex is effected by pediatric eye surgery while using Propofol? | Occulocardiac |
| Why can Propofol cause profound bradycardia? | Negative Inotropic effect. |
| What lab test should be checked routinely with Propofol? | Triglycerides |
| What two behaviors occur with Propofol? | Amorous Behavior / Intense Dreams |
| What is Etomidate classified as? | Sedative Hypnotic Chiral Compound |
| What distinct structure gives Etomidate its hypnotic properties? | Dextro Isomer |
| Which neurotransmitter is enhanced with Etomidate? | GABA |
| Etomidate has a (large/low) volume of distribution? | Large |
| What percent is Etomidate bound to albumin? | 75% |
| What condition causes a high elevation of active Etomidate in a patient? | Hypoalbuminemia |
| What metabolizes Etomidate? What percent and where are the metabolites excreted? | Ester Hydrolysis / Urine - 78% Bile - 22% |
| Unconsciousness is achieved with Etomidate in how many seconds? What is that dose? | 30-60 seconds / 0.2-0.4 mg/kg |
| T/F: Etomidate is cardiovascular stable? | True |
| Name 5 problems associated with Etomidate. | PONV. Adrenocortical Suppression. Pain with injection. Can cause seizures in those with focal epilepsy. Myoclonus |
| T/F: Etomidate can not be used to treat status epilepticus due to its pro-focal epileptic effects. | False - It can be used in patients who do not have a history of focal epilepsy. |
| How does Etomidate effect CBF/ICP/CMRO2? | Decreases CBF 35% / Decrease ICP / Decrease CMRO2 45% |
| What enzyme is effected by Etomidate, causing adrenocortical suppression? How long can the suppression last for? | 11 Beta Hydroxylase / Last 4-8 hours |
| What bar will Gary Gentner never go to again in Philadelphia? | Z Bar! |
| What property are Benzodiazepines used for? | Anxiolytic Properties |
| T/F: Benzodiazepines bind to a different part of the GABA receptor to produce their effects? | True |
| What subunit causes sedation with Benzodiazepines? | Alpha 1 subunit |
| What subunit causes anxiolytic property with Benzodiazepines? | Alpha 2 subunit |
| What do Benzodiazepines decrease degradation of? | Adenosine |
| What four effects result from increase Adenosine levels? | Decrease HR / Decrease 02 demand / Dilate Coronary Vessels / Increase Oxygen Delivery |
| What system allows the levels of Adenosine to be increased? | Nucleoside Transport System |
| What patients benefit from Adenosine? | Myocardial Ischemic patients |
| What 3 benzos do we mainly use? | Midazolam (Versed) Lorazepam (Ativan) Diazepam (Valium) |
| The 3 popular benzos have (low/high) volumes of distribution and (low/high) protein binding. | High / High |
| What percent of benzos are bound to plasma proteins? | 96-98% |
| Which benzo is most frequently used? All other bozos have which two different effects from the most popular one used? | Midazolam - all others have slower onsets / much longer durations |
| What route of administration is common Midazolam in pediatric anesthesia? What is that dose range? How long before surgery will this medication be given? | Oral - 0.5 mg/kg - 20 mg/kg / 30 minutes before. |
| T/F: Midazolam undergoes 1st pass hepatic effect? | True |
| What percent of Midazolam reaches the systemic circulation? | 50% |
| T/F: Midazolam is a potent anti-convulsant that is unable to produce an isoelectric EEG? | True |
| What is the most significant effect of Midazolam? | Ventilation depression secondary to decreased hypoxic drive. |
| Name a Benzodiazepine antagonist. | Flumazenil |
| What type of drug is Romazicon? | Benzodiazepine antagonist - (Flumazenil) |
| What is the dose range of Flumazenil? | 0.2 mg - 1 mg |
| What is the onset of action for Romazicon? | Appox. 2 minutes |
| What is the duration of action for Flumazenil? | 30-60 minutes |
| A patient with a history of seizures comes into the ER for recreational overdoes of benzodiazepine. Would this patient benefit from Flumazenil (Romazicon) antidote? | No. Romazicon is NOT recommended for patients with seizure disorders because it could precipitate acute withdrawal seizures. |
| What class of anesthetic is Ketalar? | Dissociative analgesic |
| What derivative is Ketamine? | Phencyclidine derivative |
| What type pf mixture is Ketamine? | Racemic mixture |
| What is unique about Propofol as it enters our body? | It goes through 1st pass pulmonary uptake. (MAYBE??) |
| Ketamine decreases release of a (pre/post) synaptic neurotransmitter? What is that neurotransmiter? | Pre-synaptic / Glutamate |
| What receptor site does Ketamine inhibit? | NMDA |
| What does NMDA stand for? | N-Methyl-D-Aspartate |
| What is the major excitatory neurotransmitter in the CNS? | Glutamate |
| What is the major inhibitor neurotransmitter in the CNS? | GABA |
| What does GABA stand for? | Gamma Aminobutyric Acid |
| What 3 concentration can Ketamine come in? | 10, 50, 100 mg/ml |
| What other receptor sites can Ketamine bind to? | Opioid/Monoaminergic/Muscarinic/Voltage sensitive Sodium/L-type Calcium Channels |
| What recreational drug does Ketamine mimic? | Cocaine |
| How does Ketamine mimic cocaine? | Inhibits uptake of catecholamines back into the post-ganglionic nerve ending. |
| Describe how Ketamine effects CBF/ICP/CMRO2, and then describe the most latest research on those aspects. | Ketamine is a potent cerebral vasodilator and increases all. However, it only increases CBF in the latest research. (YOU decide which concept to take to the test!) |
| T/F: Ketamine may cause myoclonus, but does not alter the seizure threshold? | True |
| T/F: Ketamine can cause burst suppression? | True |
| Which EEG lead waves are presence when Ketamine causes unconsciousness? | Theta/Delta |
| Dexmedetomidine is what type of anesthetic? | Sedative analgesic. |
| What receptor site does Precedex elicit its effect? | Selective alpha 2 agonist in the locus ceruleus? |
| What is the locus ceruleus? | Part of the Pons in the brain responsible for panic and stress. |
| T/F: Precedex can cause an increase in HR, SVR, and BP? | False, decreases HR, SVR, and BP? |
| What is the one thing we must assess more frequently when using Precedex? | HR - severe bradycardia, heart block, and asystole have been observed. |
| The CO2 response to ventilation is unchanged with which induction agent? | Dexmedetomidine |
| Yohimbine (agonizes/antagonizes) alpha 2 receptors? What type of drug is Yohimbine and what induction agent does it effect? | Antagonizes / MAOI / Precedex |
| How does Precedex effect CBF? | Decreases, with no changes in ICP/CMRO2 |
| What is Precedex's bolus dose? | 0.5-1 mcg/kg over 10 minutes |
| What is Precedex's infusion rate? | 0.2-0.7 mcg/kg/hr |
| What 3 medications are used as adjuncts for certain procedures? | Opioids, Benzodiazepines and Scopolamine |
| What can occur with large doses of narcotics? | Chest wall rigidity |
| How do you treat Chest Wall Rigidity? | Give NMBAs |
| What two drugs are know as brain "scrambling" agents? What situation are they given in? | Midazolam 5 mg / Scopolamine 0.2-0.4 mg Trauma patients with hemodynamic changes |
| Which division of opioid derivatives has opioids activity? | Phenanthrene Subdivision of Opium Alkaloids |
| What opioids are Phenanthrene Subdivision Opioid Alkaloids? | Morphine, codeine, and Thebane |
| Semisynthetic opioids result from modifications of which drug molecule? Name 2 examples. | Morphine - Codeine / Heroin |
| Name the Synthetic opioids. | Fentanyl, Alfentanyl, Sufentanil, and Remifentanyl |
| T/F: Opioids act as agonist at pre and post synaptic opioid receptors. | True |
| What are 2 other names for opioid receptors? | Stereo-specific (lock and key). |
| Where are opioid receptors located? | CNS, brainstem, spinal cord, peripheral nerves |
| Opioids mimic what endogenous peptide ligands? | Enkephalins, Endorphines, Dynorphins |
| What neurotransmitters are inhibited pre-synaptically by activating opioid receptors? | AcH, dopamine, norepinephrine, substance P |
| What electrolyte is increased with opioid effects causing the cell to be (hypopolarized/hyperpolarized)? | Potassium / Hyperpolarized |
| Name the opioid receptors. | Mu1 / Mu2 / Kappa / Delta |
| How do opioids work? | Couple guanine or (G) proteins and inhibit adenyl cyclase, decrease the conductance of voltage gated calcium channels, or open inward flowing potassium channels - with net result in decrease of neuronal activity. |
| What is the most notable feature of clinical use of opioids? | Extraordinary variation in dose requirements for pain management. |
| What is the prototype opioid by which all others are compared? | Morphine |
| When is morphine's peak effect? | 15-30 minutes |
| What are some characteristics of morphine that gives it poor CNS effects? | Rapid conjugation Poor lipid solubility Highly Ionized <0.1 at peak plasma concentration |
| What will enhance morphine's CNS penetration? | Hyperventilating the patient and making the patient alkaline and increase the non-inonized fraction of the drug. |
| What is the percent of morphine's protein binding? | 35% |
| When a patient is acidotic with high CO2 levels, cerebral blood vessels (constrict/dilate) allowing more blood flow to the brain (increasing/decreasing) morphine concentration, making the aspect of ionization not as important for morphine's effects. | Dilate / Increasing |
| T/F: Morphine undergoes ester hydrolysis? | False - conjugation in the liver. |
| What are two metabolites of morphine? | Morphine-6-glucuronide Morphine-3-glucuronide |
| Which morphine metabolite is active? | Morphine-6-glucuronide |
| What physiological response occurs with the active morphine metabolite? | Ventilation depression |
| What patient population should excellent CRNAs be cautious in giving morphine? | Renal Failure |
| What class of drugs potentiates morphine? | MAOI - by impairing formation of glucuronide conjugates. |
| Morphine exhibits greater analgesic recovery in (men/women)? | Women |
| Morphine exhibits slower speed of offset in (men/women)? | Women |
| Histamine release may occur with morphine at what IV bolus? | > 5mg |
| Which two opioids do not release histamine? | Fentanyl / Sufentanyl |
| What two medications cause CV effects when administered with morphine? What are there effects? | Opioids and Benzos - myocardial depression / decrease in CO / decrease in SVR. |
| What opioid receptor produces respiratory depression? | Mu2 |
| What does morphine do to the CO2 response curve? | Shifts curve to right. |
| What does a CO2 response curve shifting to the right signify? | A patient will require a higher PaCO2 to initiate breathing. |
| What two medications are used for cough suppression? | Codeine and Dextromethorphan |
| Which opioid is is most prevalent with chest wall rigidity? | Fentanyl |
| T/F: Opioids cause increased ICP? | True |
| How does opioids effect ICP? | Increased ICP due to increasing PaCO2 |
| Opioids cause pupil (constriction/dilation)? | Constriction |
| What is another name for Miosis? | Pupil constriction |
| What nerve is responsible for pupil changes with opioids? | Pupil constriction secondary to excitation of Edinger-Westfal nucleus of the occulomotor nerve. |
| Opioids can effect the biliary smooth muscle in which way? What two medications can be used to treat this opioid response? | NTG / Glucagon 2 mg - to decrease spasm |
| What area of the brain is responsible for N/V with opioids? | Chemoreceptor trigger zone in the 4th Ventricle |
| How potent is Demerol? | 1/10 potent as morphine (10mg morphine = 100mg Demerol) |
| What is another name for Meperidine? | Demerol |
| What is the duration of action of Meperidine? | 2 hours |
| Meperidine breaks down into (active/inactive) metabolites? What is that metabolite called? | Active / nor-meperidine |
| The metabolite of Meperidine can cause what problem? | Seizures |
| T/F: Meperidine does not release histamine? | False |
| What receptor is associated with decreasing post-op shivering with Meperidine? | Kappa Receptors |
| A patient taking which medication would be of concern with Meperidine use? | MAOIs |
| How does Meperidine effect the heart? | Negative Inotropic / Increases HR |
| How potent is Fentanyl compared to morphine? | 75-125 times more potent |
| T/F: Fentanyl has a (small/large) Vd that causes more rapid onset and shorter duration in relation to its increase lipid solubility? | Large |
| At what precent is Fentanyl protein bound? | 79%-87% |
| What dose of fentanyl will provide analgesia? | 1-2mcg/kg |
| Would you use a (small/large) dose of fentanyl for open cardiac surgery? What is the typical dose? | 50-150 mcg/kg |
| T/F: Fentanyl can be injected intrathecally? | True - for Labor 25 mcg, no side effects |
| What are two unique ways that fentanyl can be given and what are the respective doses? | Transmucosal 15-20 mcg/kg (peds - 45min before) Transdermal 50-100 mcg/kg |
| What two unique problems can make fentanyl have a secondary peak in our bodies? | Ion trapping due to acidic environment. Wash out from the lungs. |
| T/F: Opioids can cause myoclonus? | True - but no EEG changes. |
| Neonates depend on (vasoconstriction/increase HR) to maintain CO? | HR |
| Fentanyl causes what compensatory mechanism in neonates? At what does of fentanyl will this be inhibited? | Baroreceptors reflex - increase HR. 10 mcg/kg |
| T/F: Opioids can produce detectable changes in SEPS monitoring? | True - but does not interfere with interpreting the monitor while under anesthesia. |
| What is the potency of Sufentanil compared to fentanyl? | 5-12 times more potent. |
| How is sufentanil related to the lungs? | 1st pass pulmonary uptake |
| How does low protein concentrations in infants increase sufentanil's effects? | Sufentanil is highly protein bound to alpha 1 acid glycoprotein. Without proteins available, more free (active) drug is available. |
| What two metabolites occur with sufentanil metabolism? Which one is active, which one is not? | Desmethyl sufentanil 10% active N-Dealkylation inactive |
| T/F: Sufentanil can cause chest wall rigidity, similar to fentanyl? | True |
| What is Alfentanil's potency related to fentanyl? | 1/5-1/10 potent. |
| What precent does Alfentanil exist in the non-ionized formed at physiologic pH? Does it cross the BBB? | 90% / Yes |
| What CYP enzyme is responsible for Alfentanil's clearance? | CYP3A |
| What dose of Alfentanil will produce unconsciousness? What is the time of onset? | 100-300 mg/kg ?? - 45 minutes (I looked up doses and all were written in 'mcg' so I think it is 100-300 mcg). |
| Alfentanil has a (lower/higher) Vd then fentanyl? | Lower |
| Alfentanil can cause (more/less) post-op N/D when compared with fentanyl or sufentanil? | Less |
| What opioid has equianalgesic potency to fentanyl? | Remifentanyl |
| What type of metabolism does Remifentanyl undergo? Are the metabolites active or inactive? | Ester Hydrolysis / Inactive |
| T/F: Remifentanyl needs to be dosed based on real body weight due to the pharmokinetics of this drug in lean and obese patients. | False - IDEAL BODY WEIGHT, does not matter if you are fat or not. |
| T/F: Remifentanyl has a small Vd? | True |
| What is the metabolite of Remifentanyl? How much less potent is it to the Mu receptors? | Remifentanil Acid / 300-4600 fold less potent |
| What drug would be best for neurolosurgical cases? | Remifentanyl, Fast wake up. |
| What substance is Remifentanyl packaged in? What cases would be effected by this? | Glycine / Spinal and Epidural cases (glycine is a inhibitor neurotransmitter) |
| What three side effects are associated with Remifentanyl? | N/V, ventalitory depression, mild decreases in BP/HR |
| What is the potency of hydromorphine in relation to morphine? | 5 times more potent |
| What drugs are have partial agonist/partial antagonist effects? | Nalbuphine (Nubain) Butorphanol (Stadol) Buprenorphine Pentazocine Nalorphrine |
| What receptor sites do the partial agonist /partial antagonist bind to? | Mu Kappa Delta |
| What features make opioid agonist/partial antagonist desirable? | Analgesia without ventilatory depression Low physical dependency Ceiling effect (hard to overdose) |
| What drug is used for pain in OB cases? Dose? Route? | Stadol, 2-3mg IM |
| What drug can counteract the lingering post-op ventilatory depression effects? | Nubain |
| What are the three routes for Naloxone and there respective names? | Naloxone (IV) Naltrexone (oral) Nalmefene (IV) |
| What type of derivative is Naloxone? | N-alkyl derivative of oxymorphone |
| What is the dose of Naloxone? Duration of action? | 1-4 mcg / kg , 30-45 minutes |
| Naloxone can increase (sympathetic/parasympathetic) nervous activity? | Sympathetic |
| T/F: Naloxone crosses the placental barrier? | True - leads to acute withdrawal in neonates |
| TIVA is indicated for what type of patients? | Somatosensory evoked potentials SSEPS When inhaled anesthetics are contraindicated |
| How does inhaled anesthetics influence latency and amplitude of SSEPS? | Increase latency Decreases amplitude |
| What will you need to make sure you have for TIVA cases? | Enough proposal 2 (250ml) NSS bags for narcotic mixture |
| What is the concentration and infusion rate of Remifentanyl for TIVA cases? | 2mg in 250ml 0.1-0.3 mcg/kg/hour |
| What is the concentration and infusion rate of Sufentanyl for TIVA cases? | 250 mcg in 250ml 0.1-0.3 mcg/kg/hour |
| What pressor would be best for hypotensive patients for TIVA cases? | Phenylephrine |
| What is the concentration of Phenylephrine and infusion rate? | 10mg in 50ml 0.25 mcg/kg/min |
| MAC value of Nitrous Oxide? | 105 |
| Blood:Gas solubility coefficient of Nitrous Oxide? | 0.46 |
| Molecular weight of Nitrous Oxide? | 44 |
| What inhaled agent can increase air filled spaces of our body? | Nitrous Oxide |
| What emergent condition can be worsened by Nitrous Oxide? What percent N2O and how quick? | 75% N2O can can double the volume of a Pneumothorax in 10 minutes. YIKES!!! |
| What response of infection can N2O inhibit? | Inflammatory response |
| What two enzymes can be inhibited by N2O and what are these enzyme responsible for? | Methionine Synthetase - myelin formation Thymidilate Synthetase - DNA formation |
| What key comment in our body does N2O inhibit? | Vitamin B12 |
| Chronic use of N2O can lead to what problem? | Neuromuscular Symptoms - Neuropathies. |
| What can occur by turning off Nitrous Oxide and allowing patients to breath in Room Air? | Diffusion Hypoxia - N2O can dilute the alveoli because it leaves the blood stream and into the alveoli quickly. Need to exhale the N2O quickly so it doesn't cause hypoxia. |
| How can we prevent Diffusion Hypoxia cause by N2O? | Fill patients lungs with O2 after discontinuing N2O |
Created by:
gmg005
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