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Pharm (Final)

Define TIVA. an anesthetic including IV agents only; can be combined with nitrous oxide and regional
Which 2 drugs have brought back the emphasis on the IV technique? propofol and remifentanil
Which drug is the ONLY IV anesthetic that can be used as the sole agent for maintenance of TIVA? ketamine (b/c it can also be an analgesic)
What are some advantages of a TIVA? smooth induction w/ minimal coughing/hiccupping, easier control of anesthetic depth, rapid predictable emergence w/ minimal hangover, dec. incidence of emergence delirium, dec. incidence of PONV, not trigger MH, ideal for neurosurgery, no organ toxicity
What are 2 triggers of malignant hyperthermia? succinylcholine, volatiles
TIVA or balanced?: Allows smooth induction w/ minimal coughing/hiccupping. TIVA
TIVA or balanced?: Harder to control anesthetic depth. balanced anesthesia
TIVA or balanced?: Rapid, predictable emergence w/ minimal hangover. TIVA
TIVA or balanced?: Higher incidence of PONV. balanced anesthesia
TIVA or balanced?: More likely to trigger malignant hyperthermia. balanced anesthesia
TIVA or balanced?: Better for neurosurgery (b/c reduces cerebral blood flow, dec. cerebral metabolic rate for O2, allow intraop neuromonitoring) TIVA
TIVA or balanced?: More potential for organ toxicity. balanced anesthesia
TIVA or balanced?: Less risk of atmospheric pollution. TIVA
TIVA or balanced?: Decreases intraoperative sympathetic stimulation. TIVA
TIVA or balanced?: Better at maintaining autoregulation of cerebral blood flow. TIVA
TIVA or balanced?: Higher risk of bleeding in surgical field? balanced anesthesia
TIVA or balanced?: Improves mucociliary transport. TIVA
TIVA or balanced?: Improves V/Q matching. TIVA (less dead space)
TIVA or balanced?: Increased catecholamine release. balanced anesthesia
TIVA or balanced?: Increased cost. TIVA
What are 5 indications for TIVA? 1)MH susceptible pts, 2)cystic fibrosis pts, 3)airway endoscopies/laryngeal/tracheal surgery, 4)remote locations, during transportation, 5)pts with intracranial HTN/neuro cases
What are 6 advantages to a continuous infusion TIVA vs. intermittent bolus TIVA? 1)minimize swings in levels of drugs, 2)reduced total drug requirements by 25-30%, 3)fewer side effects (resp depression), 4)shorter recovery times, 5)decreased cost, 6)stable depth of anesthesia
What should you expect after a rapid bolus dose injected quickly? rapid onset of unconsciousness, decreased BP, apnea
What should you expect after initiation of a continuous infusion? slower onset of unconsciousness, lower dose of drug used, minimized side effects
What drug is most commonly used in TIVA? propofol
Does propofol burn on injection? yes
What is the % of apnea with propofol? 25-30% (higher w/ opioids)
Does propofol provide analgesia? no
What drugs reduce the required induction dose of propofol? midazolam, opioids
Propofol has (high or low?) accumulation. low; early restoration of cognitive and psychomotor function
True or False: PONV rates are similar in pts w/ TIVA w/o antiemetic and volatile w/ antiemetic? True
True or False: TIVA is less effective as an anti-emetic as an independent variable reducing PONV. False: It is just as effective as any anti-emetic
What effects does ketamine have? hypnosis, analgesia, amnesia
True or False: Ketamine causes sympathetic stimulation. True (catecholamine release); however, it is a myocardial depressant at baseline
What are some limiting factors of ketamine? HTN, tachycardia, psychologic reactions
Why is ketamine not a preferred choice for neuro cases? increases ICP
You should d/c ketamine _______min before emergence. 30min
Ketamine has an (increased or decreased?) incidence of PONV. increased (unless combined w/ propofol)
How can you offset the unpleasant hallucinations assoc. w/ ketamine? pretreat w/ benzo or combine w/ propofol
What is the nickname given to the combinations of ketamine and propofol? white lightening
What are 3 advantages to using a combo of ketamine and propofol? 1)offsetting hemodynamic effects, 2)offsetting respiratory effects, 3)propofol offsets PONV and hallucinations
How (doses?) would you administer "white lightening"? 1)mix ketamine 2mg/mL of propofol, 2)induce w/ 1-2mg/kg of propofol in mixture, 3)give an additional 0.5-1 mg/kg of ketamine after LOC, 4)infuse 140-200 mcg/kg/min for first 10 min, 5)100-140mcg/kg/min for next 2 hrs, 6)80-120mcg/kg/min after 2 hrs
What are 5 advantages to using remifentanil during TIVA? 1)rapid onset, 2)allows high-dose opioids w/o delayed recovery NO MATTER the length of infusion time, 3)titrates easily, 4)quick emergence, 5)decreased PONV
What are 2 disadvantages to using remifentanil during TIVA? 1)increased shivering, 2)increased post-op pain
What is the bolus dose of remifentanil? not one! never bolus
What is the infusion dose of remifentanil? turn infusion on at 1mcg/kg/min, maintain at 0.1-0.4mcg/kg/min
How is remifentanyl metabolized? plasma esterases
Turn off remifentanyl ________min before extubation. 5-7min
You should start ____________ prior to d/c'ing remifentanil. post-op analgesia
What kind of cases use dexmetetomidine? sedation cases
What are the effects of dexmetetomidine? anxiolysis, analgesia
Dexmetetomidine has a (longer or shorter?) recovery than propofol? Why? longer: r/t higher doses required for anesthesia
What are 2 advantages to using dexmetetomidine? 1)reduced need for opioids, 2)dec. PONV
What is the most reliable sign of inadequate anesthesia? movement
You want to maintain _______ twitches of ToF to allow movement. 1-2
Anticipate increased med requirements during... intubation and skin incision
Anticipate decreased med requirements during... prep and drape
Describe the "daredevil" way to titrate infusions during TIVA. if no mvmt in 10-15min, decrease rate by 20%. If pt responds, administer a bolus and increase the rate to a point between the first and second rate.
Which analgesic is the only one that should be titrated? remifentanil
What is used as a guide for emergence from anesthesia to help determine when infusions should be d/c'd. context-sensitive half time
Rate diazepam, midazolam, etomidate, propofol, ketamine, and thiopental in order of CSHT from shortest to longest. etomidate < propofol = ketamine < midazolam < thiopental < diazepam
Rate fentanyl, remifentanil, alfentanil and sufentanil is order of CSHT from shortest to longest. remifentanil < sufentanil < alfentanil < fentanyl
What is propofol's CSHT up to 3 hrs? 10 min
What is propofol's CSHT after 3hrs? 25 min
What is propofol's CSHT after 8 hrs? 40 min
What is thiopental's CSHT? 40-300 min
What is ketamine's CSHT after 8 hrs? 50 min
What is remifentanil's CSHT? 4 min (independent of infusion time)
What is sufentanil's CSHT after 4 hrs? 30 min
What size syringes can be used for TIVA? 20, 30, 60 mL
What type of tubing is used for TIVA? low-volume tubing
What are a few ways to trouble-shoot the TIVA pump? insure infusion is reaching pt: 1)look for disconnections, 2)check programming of pump, 3)correct set-up/ plunger in clamp, 4)position of stopcock
True or False: TIVA infusion devices require more time for set-up and maintenance. True
True or False: In cases up to 1 hr, TIVA and balanced cases have equal hemodynamic stability and similar recovery. True
What are Drager-Zeus Infinity Empowered pumps? syringe pumps are on anesthesia machine
What are Target-Controlled Infusion pumps? can titrate predicted blood concentration of the drug as simply as volatiles for varying levels of surgical stimulation and individual patient requirements