2) Anesthetic Techniques, Case Prep, Intro Pharm

what factors do you consider when picking an anesthetic technique?

• preference of patient, anesthesiologist, and surgeon

• coexisting diseases (ex: asthma, GERD, diabetes)

• site of surgery

• body position of patient during surgery

• elective or emergency surgery

• likelihood of increased amounts of gastric contents at the time of induction of anesthesia

• suspected difficult airway management and tracheal intubation

• duration of surgery

• patient age

• anticipated recovery time

• postanesthesia care unit discharge criteria

how do you check if the patient is asleep?

eye-lash test

what must you prove before induction?

you can breath for the patient

if a spontaneously breathing patient has a nasal cannula starts breathing through the mouth, how will you analyze their EtCO2?

• move cannula down to mouth or chin lift

  • cannula not totally accurate due to room air mixing in or mouth breathing → just want continuity of capnography

what are the general anesthesia maitenance goals?

• amnesia

• analgesia

• skeletal muscle relaxation

• hemodynamic control

what are 3 kinds of regional anesthesia?

neuraxial (ex: spinal, epidural)

peripheral nerve blocks (ex: upper/lower extremity)

intravenous regional anesthesia (ex: bier block)

what are the MAC goals?

• diagnose clinical problems during procedure

• administer sedatives, analgesics, hypnotics, other meds

• psychological support

• physical comfort

• support vital functions

what’s the acronym for room set up?

• Drugs

• Airway

• Machine

• Monitors

• IV

• Tape, tank, table, transfusion

• Suction

if bleeding begins due to a nasal airway, what should you do?

leave the nasal airway in and suction blood from airway

what can you mix with lube for nasal airways to avoid nose bleeding?

phenylephrine

what is a bite block used to prevent?

patient biting on tube during wake up and negative pressure pulmonary edema

how does microdrip tubing differ from macrodrip tubing?

microdrip tubing always delivers 60 drops/mL, while macrodrip tubing varies (10, 15, 20 drops/mL)

what antibiotics must you give within 1 hour of incision?

ancef, clindamycin, gentamycin, unasyn

what antibiotics must you give within 2 hours of incision?

levaquin, vancomycin

other than the 2 major non-depolarizing muscle relaxants (roc & vec), what alternative NDMRs could you use?

• cisatracurium (Nimbex) → used in patients with underlying kidney disease because it’s broken down by Hoffman elimination

• pancuronium (Pavulon)

describe how succinylcholine (Anectine) works

• looks like 2 acetylcholine molecules

• binds to ACh receptors, triggering them to stay in depolarizing state until it gets broken down

define minimum alveolar concentration (MAC) and provide the MACs for the 4 major inhalation anesthetic agents.

• MAC: the concentration of an inhaled anesthetic in the lungs that stops 50% of patients from moving during a surgical skin incision

• desflurane (Suprane): 6%

• isoflurane (Forane): 1.2%

• sevoflurane (Ultane): 2%

• nitrous oxide: 104% → can’t achieve this without providing a hypoxic mixture, machines are typically limited to providing a max of 75% nitrous to 25% oxygen

what are 3 major drugs that mimic the actions of the sympathetic nervous system and result in the constriction of blood vessels?

ephedrine, epinephrine, phenylephrine

which of the sympathetic nervous system mimetics is indirect and why?

ephedrine because it triggers the adrenal glands for norepinephrine & epinephrine release

which of the sympathetic nervous system mimetics is a catecholamine that increases contractility?

epinephrine

does esmolol or labetalol have a quicker onset?

esmolol

considering labetalol, which decreases more: BP or HR?

BP decreases more than HR

how does sugammadex reverse paralysis?

• binds with and encapsulates rocuronium/vecuronium, stopping the competition between rocuronium/vecuronium and acetylcholine

• removes rocuronium/vecuronium via urine

how does neostigmine reverse paralysis

stops the breakdown/reuptake of acetylcholine after it’s been released from the nicotinic nerve terminal → floods nerve terminal with acetylcholine to overcompensate for all the rocuronium present

why do you have to give anticholinergics (glycopyrrolate) with anticholinesterases (neostigmine)?

• neostigmine causes a build up of acetylcholine in the body → activates parasympathetic NS

• parasympathetic NS activation can cause BLUDS: bradycardia, lacrimation, urination, defecation, and salivation

• glycopyrrolate blocks parasympathetic NS response by being a competitive antagonist of muscarinic receptors

if you give someone with a anticholinesterase deficiency succinylcholine and the paralysis isn’t wearing off, what do you do?

give roc/vec and sugammadex so that the competition of acetylcholine stops

when the patient won’t wake up, but everything else makes sense clinically, what should you try giving?

benzo antagonist

how do local anesthetics work?

block nerve transmission via sodium channel inhibition

what are the 5 rights to check before administering any drug?

drug, dose, patient, time, route

which beta blocker is selective and for what receptors?

esmolol, beta 1 receptors in heart

what does an alpha 1 antagonist do?

dilate blood vessels

what does a beta 2 antagonist do?

bronchoconstriction

what receptors does labetalol block?

alpha 1 in heart and beta 2 in lungs