Pharm (Final)
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| Define TIVA. | an anesthetic including IV agents only; can be combined with nitrous oxide and regional
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| Which 2 drugs have brought back the emphasis on the IV technique? | propofol and remifentanil
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| 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)
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| 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
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| What are 2 triggers of malignant hyperthermia? | succinylcholine, volatiles
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| TIVA or balanced?: Allows smooth induction w/ minimal coughing/hiccupping. | TIVA
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| TIVA or balanced?: Harder to control anesthetic depth. | balanced anesthesia
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| TIVA or balanced?: Rapid, predictable emergence w/ minimal hangover. | TIVA
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| TIVA or balanced?: Higher incidence of PONV. | balanced anesthesia
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| TIVA or balanced?: More likely to trigger malignant hyperthermia. | balanced anesthesia
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| TIVA or balanced?: Better for neurosurgery (b/c reduces cerebral blood flow, dec. cerebral metabolic rate for O2, allow intraop neuromonitoring) | TIVA
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| TIVA or balanced?: More potential for organ toxicity. | balanced anesthesia
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| TIVA or balanced?: Less risk of atmospheric pollution. | TIVA
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| TIVA or balanced?: Decreases intraoperative sympathetic stimulation. | TIVA
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| TIVA or balanced?: Better at maintaining autoregulation of cerebral blood flow. | TIVA
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| TIVA or balanced?: Higher risk of bleeding in surgical field? | balanced anesthesia
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| TIVA or balanced?: Improves mucociliary transport. | TIVA
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| TIVA or balanced?: Improves V/Q matching. | TIVA (less dead space)
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| TIVA or balanced?: Increased catecholamine release. | balanced anesthesia
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| TIVA or balanced?: Increased cost. | TIVA
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| 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
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| 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
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| What should you expect after a rapid bolus dose injected quickly? | rapid onset of unconsciousness, decreased BP, apnea
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| What should you expect after initiation of a continuous infusion? | slower onset of unconsciousness, lower dose of drug used, minimized side effects
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| What drug is most commonly used in TIVA? | propofol
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| Does propofol burn on injection? | yes
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| What is the % of apnea with propofol? | 25-30% (higher w/ opioids)
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| Does propofol provide analgesia? | no
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| What drugs reduce the required induction dose of propofol? | midazolam, opioids
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| Propofol has (high or low?) accumulation. | low; early restoration of cognitive and psychomotor function
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| True or False: PONV rates are similar in pts w/ TIVA w/o antiemetic and volatile w/ antiemetic? | True
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| 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
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| What effects does ketamine have? | hypnosis, analgesia, amnesia
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| True or False: Ketamine causes sympathetic stimulation. | True (catecholamine release); however, it is a myocardial depressant at baseline
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| What are some limiting factors of ketamine? | HTN, tachycardia, psychologic reactions
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| Why is ketamine not a preferred choice for neuro cases? | increases ICP
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| You should d/c ketamine _______min before emergence. | 30min
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| Ketamine has an (increased or decreased?) incidence of PONV. | increased (unless combined w/ propofol)
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| How can you offset the unpleasant hallucinations assoc. w/ ketamine? | pretreat w/ benzo or combine w/ propofol
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| What is the nickname given to the combinations of ketamine and propofol? | white lightening
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| 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
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| 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
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| 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
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| What are 2 disadvantages to using remifentanil during TIVA? | 1)increased shivering, 2)increased post-op pain
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| What is the bolus dose of remifentanil? | not one! never bolus
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| What is the infusion dose of remifentanil? | turn infusion on at 1mcg/kg/min, maintain at 0.1-0.4mcg/kg/min
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| How is remifentanyl metabolized? | plasma esterases
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| Turn off remifentanyl ________min before extubation. | 5-7min
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| You should start ____________ prior to d/c'ing remifentanil. | post-op analgesia
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| What kind of cases use dexmetetomidine? | sedation cases
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| What are the effects of dexmetetomidine? | anxiolysis, analgesia
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| Dexmetetomidine has a (longer or shorter?) recovery than propofol? Why? | longer: r/t higher doses required for anesthesia
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| What are 2 advantages to using dexmetetomidine? | 1)reduced need for opioids, 2)dec. PONV
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| What is the most reliable sign of inadequate anesthesia? | movement
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| You want to maintain _______ twitches of ToF to allow movement. | 1-2
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| Anticipate increased med requirements during... | intubation and skin incision
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| Anticipate decreased med requirements during... | prep and drape
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| 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.
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| Which analgesic is the only one that should be titrated? | remifentanil
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| What is used as a guide for emergence from anesthesia to help determine when infusions should be d/c'd. | context-sensitive half time
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| Rate diazepam, midazolam, etomidate, propofol, ketamine, and thiopental in order of CSHT from shortest to longest. | etomidate < propofol = ketamine < midazolam < thiopental < diazepam
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| Rate fentanyl, remifentanil, alfentanil and sufentanil is order of CSHT from shortest to longest. | remifentanil < sufentanil < alfentanil < fentanyl
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| What is propofol's CSHT up to 3 hrs? | 10 min
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| What is propofol's CSHT after 3hrs? | 25 min
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| What is propofol's CSHT after 8 hrs? | 40 min
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| What is thiopental's CSHT? | 40-300 min
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| What is ketamine's CSHT after 8 hrs? | 50 min
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| What is remifentanil's CSHT? | 4 min (independent of infusion time)
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| What is sufentanil's CSHT after 4 hrs? | 30 min
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| What size syringes can be used for TIVA? | 20, 30, 60 mL
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| What type of tubing is used for TIVA? | low-volume tubing
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| 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
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| True or False: TIVA infusion devices require more time for set-up and maintenance. | True
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| True or False: In cases up to 1 hr, TIVA and balanced cases have equal hemodynamic stability and similar recovery. | True
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| What are Drager-Zeus Infinity Empowered pumps? | syringe pumps are on anesthesia machine
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| 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
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