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