LAST Motha Fukin PHARM TEST 🥳

1. Surgery

1. Surgery

What is anesthesia produced by a mixture of drugs, often including both inhaled and intravenous agents?

Balanced Anesthesia

What is anesthesia induced by inhalation of drug?

Inhalation anesthesia

What is the alveolar concentration of an anesthetic that is required to prevent a response to a standardized painful stimulus in 50% of patients?

Minimum alveolar anesthetic concentration (MAC)

What is a a state of decreased awareness of pain, sometimes with amnesia?

Analgesia

What is a a state of unconsciousness, analgesia, and amnesia, with

skeletal muscle relaxation and loss of reflexes?

General Anesthesia

Amnesia vs Analgesia:

Pt cannot consciously recall or recognize events to which he/she had been exposed during general anesthesia

Amnesia

Amnesia vs Analgesia:

A state of insensitivity to pain even though the person remains fully conscious

Analgesia

What are the Inhaled Anesthetics?

- Isoflurane

- Desflurane

- Sevoflurane

- Nitrous oxide (laughing gas)

- Halothane

- Enflurane

What are the IV Anesthetics

- Barbiturates

- Benzodiazepines

- Propofol

- Ketamine

- Opioids

What dosage form is for the maintenance of anesthesia? (Intravenous/Inhalation)

Inhalation route

What dosage form is for the induction of anesthesia? Intravenous/Inhalation)

Intravenous route

What are the stages of Anesthesia?

I Stage of Analgesia

II Stage of Excitement

III Stage of Surgical Anesthesia

IV Stage of Medullary Depression

What stage of Anesthesia:

- Initially, the pt experiences analgesia without amnesia

- Towards the end of stage I, both analgesia and amnesia are produced

I Stage of Analgesia

What stage of Anesthesia:

- Patient appears delirious and may vocalize

- Patient is amnestic

- Irregular respiration

- Retching/vomiting may occur (RISK FOR ASPIRATION)

- Rapidly increase the concentration to limit duration of this stage

II Stage of Excitement

What stage of Anesthesia:

- Recurrence of regular respiration

- Complete cessation of spontaneous respiration (apnea)

III Stage of Surgical Anesthesia

What stage of Anesthesia:

- Deep stage

- Severe CNS depression → vasomotor center in medulla, resp center in brain stem

- Without circulatory and resp support, death rapidly ensues

IV Stage of Medullary Depression

What are the 4 planes of Stage III Anestesia?

1. Cortical centers

2. Basal ganglia

3. Spinal cord

4. Medulla

Drugs with a low blood:gas partition coefficient equilibrate more ___________ than those with a higher blood solubility

rapidly

What factors does the rate of therapeutic concentration depend on?

Solubility properties

Volume of pulm ventilation

Pulm blood flow

Partial pressure gradient between arterial and mixed venous blood anesthetic concentrations

What is the MOA of inhaled/IV anesthetics?

GABA-A receptor-chloride channel = primary target of general anesthetics

What type of receptors do inhaled and IV anesthetics with sedative/hypnotic properties directly activate?

GABA-A receptors

A lower minimum alveolar anesthetic concentration (MAC) would indicate we have a (less/more) potent drug?

more potent

NOTE: higher MAC would indicate a less potent drug

What factors decrease the MAC (requiring less anesthetic)?

- Elderly

- Hypothermia

What factors increase the MAC (requiring more anesthetic)?

- Pregnancy

- Alcohol Abuse

- Chronic use of centrally acting drugs

T/F: A patients sex, height, and weight can affect the minimum alveolar anesthetic concentration?

False

Does Halothane (Fluothane) provide both anesthesia and analgesia?

No, just anesthesia

need another anesthetics for analgesia (e.g., thiopental, nitrous oxide, oxygen or muscle relaxants)

How is Halothane (Fluothane) eliminated?

Exhaled

What has a more rapid onset of anesthesia:

Halothane (Fluothane) or Enflurane (Ethrane)

Enflurane (Ethrane)

What are the side effects of Enflurane (Ethrane)?

- Respiratory Depression

- Lower incidence of arrhythmias than Halothane

- Hypotension

- EEG changes due to seizure

- Hepatic and renal dysfunction

How fast is the onset and recovery with Desflurane (Suprane)?

Poor induction but rapid recovery (5 min)

What are the side effects of Isoflurane (Forane)?

Respiratory Depression

Increased CO

HypOtension

little post-anesthetic organ tox or seizures

What are the side effects of Desflurane (Suprane)?

Myocardial depression

Resp depression

Coronary and cerebral artery dilation

Laryngospasm

What unique life threatening side effect can occur from the use of Desflurane (Suprane)?

Laryngospasms

Why is Isoflurane (Forane) used more than Halothane (Fluothane) and Enflurane (Ethrane)?

More rapid induction of anesthesia

Faster Awakening

No risk of arrhythmias

Which inhaled anesthetic would be best used in an outpatient setting where we don't care much about how fast the patient is put to sleep, but we want the recovery/awakening time to be rapid (~ 5 minutes)?

Desflurane (Suprane)

HINT: "Suprane"--> "super" quick

What are the side effects of Sevoflurane (Ultrane)?

N/V -- can give Zofran

Agitation

Bradyarrhythmia

Hypotension

Tachyarrhythmia

What are the clinical uses for Nitrous Oxide?

Outpatient dental procedures and supplement to more potent anesthetics

Is Nitrous Oxide effective as a single agent?

No → incomplete anesthetic

Good for minor procedures (Ex: Dental)

Long term use of Nitrous Oxide can cause depletion of what Vitamin?

B12

Nitrous oxide can expand the volume of gas in different air cavities, what are some examples of this?

Distended bowel

Ruptured tympanic membrane

Pneumothorax

What are the contraindications of Nitrous Oxide?

Pregnant Women

Immunosuppressed pts

Pernicious anemia

Which inhaled anesthetic has a rapid onset (induction) and rapid recovery?

Sevoflurane (ultrane)

What are the toxicity risks of Anesthetics?

Hepatotoxicity

Nephrotoxicity

Malignant hyperthermia

What is an autosomal dominant genetic disorder that occurs in individuals undergoing general anesthesia?

Malignant Hyperthermia

Patient arrives to the post op recovery center and is experiencing rapid onset tachycardia, hypertension, severe muscle rigidity, and a high fever. On labs, they pt is also hyperkalemic. What is a life threatening condition you should be cautious about?

Malignant Hyperthermia

What is the most reliable test to see if someone is susceptible to acquiring malignant hyperthermia as a result of undergoing general anesthesia?

In vitro caffeine-halothane contracture test

What is the treatment for Malignant Hyperthermia?

1. Dantrolene (Dantrium, Ryanodex, Renvonto)

2. Reduce Body Temp (IVF)

3. Restore electrolytes/acid-base balance (bicarb)

What does Dantrolene (Dantrium, Ryanodex, Renvonto) do in the treatment of Malignant Hyperthermia?

Reduces calcium release from sarcoplasmic reticulum

What should be given following (or before??) surgery to combat N/V?

5HT3 antagonist → Zofran

Do inhaled or intravenous anesthetics have a faster onset of action?

Intravenous

What adjunctive meds are used with Anesthetics?

Barbiturates (Thiopental) → Sedation

Benzos → control anxiety/facilitate amnesia

Opioids → Analgesia

Anticholinergics → Amnesia

Propafol

Etomidate

Ketamine

Zofran → antiemetic

What class of drugs are preferred for patients needing anesthesia for electroconvulsive therapy (ECT)?

Barbiturates → Thiopental, Phenobarbital, Pentobarbital

lacks analgesic properties

What binds to the GABA receptor and reversibly depress the activity of all excitable tissues in the CNS?

Barbiturates → Thiopental, Phenobarbital, Pentobarbital

What are the side effects of Barbiturates?

Decreased BP, CO, ICP (cerebral swelling d/t trauma)

How does Nitrous Oxide affect Thiopental dose?

Reduces required dose

Which intravenously given anesthesia drug is preferred for patients with cerebral swelling?

Thiopental (barbiturate)

What class of drugs are preferred as pre-medication before administering anesthesia?

HINT: Also controls acute agitation

Benzodiazepines → Diazepam, Lorazepam, Midazolam

What has sedative, anxiolytic and amnestic properties?

Benzodiazepines → Diazepam, Lorazepam, Midazolam

Which bBenzodiazepine is the most common and the drug of choice for pre-medicating patients before anesthesia?

Midazolam (Versed) → high incidence of amnesia with rapid onset and shorter elimination half-life

NOTE: can be given intranasally

What is our benzodiazepine antagonist (antidote)?

Flumazenil (Romazicon) → aids to accelerate recovery, short duration of action

What is a dangerous effect of Flumazenil (Romazicon) use in chronic benzo users?

Withdrawal → risk for seizures

What is a adverse effect from Fentanyl that could disrupt ventilation if given too quickly? (Kahoot Q)

Chest wall rigidity

What are the cons of opioid analgesic use?

Increased post op morbidity (prolonged vent, GI/bladder comps)

Chest wall rigidity may impair ventilation (only fentanyl)

Which opioids are used for rapid onset of action and are used as co-induction agents with IV sedative-hypnotic anesthetics

- Remifentanil

- Alfentanil

Which opioid analgesics are used with anesthetics?

- Morphine

- Fentanyl

- Sufentanil

- Remifentanil (potent, short acting)

- Alftenanil

What is the GOLD STANDARD for post op pain?

Morphine

What is the DOC for ambulatory surgery?

Propofol (Diprivan)

How does Propofol (Diprivan) compare to barbiturates?

Onset of action is similar but recovery is more rapid and pts are able to ambulate earlier

T/F: Propofol (Diprivan) has a reduced chance of developing nausea and vomiting compared to other general anesthetics.

True

Why might we see patients developing hypertriglyceridemia who are on big doses of propofol (Diprivan) in the ICU?

Propofol (Diprivan) has to be in a lipid emulsion in order to be administered, so the patient is receiving exogenous lipids with the medication. (hence why the liquid is white) Milky!

Besides the triglycerides, what else should we monitor patients for when administering prolonged infusions of Propofol (Diprivan)?

Severe acidosis due to propofol related infusion syndrome (PRIS)

How is Propofol (Diprivan) excreted?

Urine → can turn it green

What is our main adverse effect from the use of Propofol (Diprivan)?

HypOtension

Which drug is used for induction of anesthesia in pts with limited CV reserve?

Etomidate → minimal CV and resp. depression, minimal hypotension

rapid LOC!

What should be administered with Etomidate?

Opioid analgesics bc it has no analgesic effects

Ex's of Opioid Analgesics →

Morphine, Fentanyl, Sufentanil, Remifentanil (potent, short acting), Alftenanil

What kind of general anesthetic is useful if you need to set a bone back in place or you need to rapidly intubate?

HINT: this drug has rapid loss of consciousness and rapid recovery but has no analgesic effects!!!

(Important)

Etomidate

NOTE: Must use with opioid analgesics

What are the adverse effects of Etomidate?

Myoclonic

Post op N/V

Adrenocortical suppression (lowers BP and glucose)

Which general anesthetic has a unique adverse effect of causing adrenocortical suppression?

Etomidate → could lead to hypotension/hypoglycemia

How is Etomidate metabolized?

Hepatically

Which anesthetic drug works by blocking glutamic acid at the NMDA receptor?

HINT: also treats depression

Ketamine

What is the Sedative of Choice for Status Asthmaticus?

Ketamine → anesthetic and analgesic properties

T/F: Ketamine can decrease intracranial pressure and cerebral blood flow?

FALSE!

DO NOT use with head injuries

Remember Barbiturates (thiopental) do that and Ketamine actually increases ICP and blood flow

What drug has a high incidence of postop psychic phenomena, esp in the elderly?

Ketamine

Note to self - look back at recording for slide 60 to see if there is anything else I need to add

Note to self - look back at recording for slide 60 to see if there is anything else I need to add

Which drugs are used for conscious sedation?

- Diazepam

- Midazolam

- Propofol

- Ketamine

What are the benefits to using Benzos and Opioids for analgesic and anesthesia properties?

They are reversible!

Benzos → Flumazenil (Romazicon)

Opioids → Naloxone (Narcan)

What is dexmedetomidine (Precedex) used for?

Sedative and analgesic effects → Alpha 2-Agonist

Which drug would be commonly used for a patient who has been on the ventilator for a while but is now ready to come off of it but we still want to keep them lightly sedated?

HINT: This drug is an Alpha 2-Agonist

Dexmedetomidine (Precedex)

What are the adverse effects seen with high doses of Dexmedetomidine (Precedex)?

Hypotension

Bradycardia

What are the Adjunct Agents?

BZDs → Control anxiety, facilitate amnesia

Barbiturates → Sedation

Antihistamines:

→ Diphenhydramine: Prevention of allergic reactions

→ Famotidine: Reduce gastric acidity

Ondansetron → Antiemetic

Opioids → Analgesia

Anticholinergics → Amnesia

What reversibly block impulse conduction along nerve axons → sodium channel and action potential inhibition?

Local Anesthetics "-caine"

What type of channels do local anesthetics block?

Sodium channels

What was the FIRST anesthetic (1860)?

Fun fact that was mentioned twice so why not

Cocaine

What may antagonize the action of local anesthetics?

Elevated Extracellular Calcium

What may enhance the effects of local anesthetics?

Elevated Extracellular Potassium

Which places can you not inject vasoconstrictors bc it can cause vasoconstriction and tissue injury?

- Fingers

- Toes 👣

- Penis 🍆

- Nose 👃

Which local anesthetics are more potent and have longer duration of action?

- Tetracaine

- Bupivacaine

- Ropivacaine

Which local anesthetics are short acting?

- Procaine

- Chloroprocaine

Which local anesthetics are intermediate-acting?

- Lidocaine

- Mepivacaine

- Prilocaine