CHAPTER 08- ANESTHESIA.txt

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CHAPTER 08- ANESTHESIA.txt
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2012-01-07 17:57:26
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  1. MAC:
    • 1) minimum alveolar concentration= smallest concentration of inhalational agents which 50% of patients will not move with incision
    • 1- Small MAC--> more lipid soluble= more potent
    • 2- speed of induction is inversely proportional to solubility
    • 3- nitrous is fastest but has high MAC (low potency)
  2. Inhalational agents cause:
    • 1) unconsciousness, amnesia, and some degree of analgesia
    • 2) blunt hypoxic drive
    • 3) most are associated with some degree of myocardial depression, increased cerebral blood flow, and decreased renal blood flow
  3. NO2 (nitrous oxide):
    • 1) fast
    • 2) minimal myocardial depression
  4. Halothanes-
    • 1) slow
    • 2) highest degree of cardiac depression and arrhythmias
    • 3) least pungent (which is good for children)
    • 4) Halothane hepatitis:
    • 1- fever
    • 2- eosinophilia
    • 3- jaundice
    • 4- increased LFTs
  5. Enflurane
    can cause seizures
  6. Isoflurane
    • 1) good for neurosurgery
    • 2) higher cost
  7. Sevoflurane
    • 1) less myocardial depression
    • 2) fast onset/offset
    • 3) less laryngospasm
    • 4) higher cost
  8. Induction agents (slides to follow):
  9. Sodium thiopental (barbiturate):
    • 1) fast acting
    • 2) Side effects:
    • 1- decreased cerebral blood flow and metabolic rate
    • 2- decreased blood pressure
  10. Propofol
    • 1) very rapid distribution and on/off
    • 2) amnesia
    • 3) sedative
    • 4) Side effects:
    • 1- hypotension
    • 2- respiratory depression
    • 5) not an analgesic
    • 6) do not use in patients with egg allergy
    • 7) metabolized in liver and by plasma cholinesterases
  11. Ketamine:
    • 1) dissociation of thalamic/limbic systems; places patient in a cataleptic state (amnesia, analgesia)
    • 2) No respiratory depression
    • 3) Side effects:
    • 1- hallucinations
    • 2- catecholamine release (increased carbon monoxide, tachycardia)
    • 3- increased airway secretions
    • 4- increased cerebral blood flow
    • 4) contraindicated for patients with head injury
    • 5) good for children
  12. Etomidate:
    • 1) fewer hemodynamic changes; fast acting
    • 2) continuous infusions can lead to adrenocortical suppression
  13. rapid sequence intubation:
    • Can be indicated for:
    • 1) recent oral intake
    • 2) GERD
    • 3) delayed gastric emptying
    • 4) pregnancy
    • 5) bowel obstruction
  14. What is the last muscle to go down and 1st muscle to recover from paralytics?
    Diaphragm
  15. Whats the 1st muscle to go down and last to recover from paralytics?
    neck muscles and face
  16. Depolarizing agent:
    Depolarizing agent- the only one is succinylcholine
  17. Succinylcholine
    • 1) fast, short acting
    • 2) causes fasciculations at first
    • 3) increased ICP, many side effects
    • 4) Side effects:
    • 1- malignant hyperthermia
    • 2- defect in calcium metabolism
    • 3- calcium released from sarcoplasmic reticulum causes muscle excitation- contraction syndrome
    • 4- Side effects: 1st sign is increased end-tidal CO2, then fever, tachycardia, rigidity, acidosis, hyperkalemia
    • 5) Tx: dantrolene (10mg/kg) inhibits Ca release and decouples excitation complex, cooling blankets, HCO3, glucose, supportive care
    • 6) hyperkalemia- depolarization releases K
    • 7) Do not use in:
    • 1- burn patients
    • 2- neurologic injury
    • 3- neuromuscular disorders
    • 4- spinal cord injury
    • 5- massive trauma
    • 6- acute renal failure
    • 8) open angle glaucoma can become closed-angle glaucoma
    • 9) atypical pseudocholinesterases- cause prolonged paralysis (asians)
  18. Nondepolarizing agents:
    • 1) inhibit neuromuscular junction by competing with acetylcholine
    • 2) can get prolongation of these agents with:
    • 1- hypothermia
    • 2- hypercarbia
    • 3- certain antibiotics
    • 4- electrolyte abnormalities
    • 5- myasthenia gravis
  19. Cis-atracurium
    • 1) undergoes Hoffman degradation
    • 2) can be used in liver and renal failure
    • 3) histamine release
  20. Mivacurium
    • 1) fast, short acting
    • 2) degradation by plasma cholinesterases
    • 3) histamine release
  21. Rocuronium
    • 1) fast, intermediate acting
    • 2) hepatic metabolism
  22. Pancuronium
    • 1) slow acting, long lasting
    • 2) renal metabolism
    • 3) most common side effect: tachycardia
  23. Reversing drugs for nondepolarizing agents (slides to follow):
  24. Neostigmine:
    • 1) counters nondepolarizing agents
    • 2) blocks acetylcholinesterase
    • 3) increases acetylcholine
  25. Edrophonium
    • 1) counters nondepolarizing agents
    • 2) blocks acetylcholinesterase
    • 3) increases acetylcholine
  26. Atropine or glycopyrrolate
    1) should be given with neostigmine or edrophonium to counteract effects of generalized acetylcholine overdose
  27. Local Anesthetics:
    • 1) work by increasing action potential threshold, preventing Na influx
    • 2) can use 0.5cc/kg of 1% lidocaine
    • 3) infected tissues hard to anesthetize secondary to acidosis
    • 4) Length of action: bupivicaine > lidocaine > procaine
    • 5) Epinephrine allows higher doses to be used, stays locally
    • 1- No epinephrine with:
    • a- arrhythmias
    • b- unstable angina
    • c- uncontrolled hypertension
    • d- poor collaterals (penis/ear)
    • e- uteroplaental insufficiency
    • 6) Side effects:
    • 1- tremors
    • 2- seizures
    • 3- tinnitus
    • 4- arrhythmias
    • (CNS symptoms occur before cardiac)
  28. Amides:
    • (all have an "i" in the first part of the name)
    • 1) lidocaine
    • 2) bupivicaine
    • 3) mepivacaine
    • 4) rarely allergic reactions
  29. Esters
    • 1) tetracaine
    • 2) procaine
    • 3) cocaine
    • Increased allergic reactions secondary to PABA analogue
  30. Narcotics (opiods)
    • 1) Morphine, fentanyl, demerol, codeine
    • 2) act on mu receptors
    • 3) profound analgesia, respiratory depression (decreased CO2 drive), no cardiac effects, blunt sympathetic response
    • 4) metabolized by the liver and excreted via kidney
    • 5) Overdose of narcotic drugs--> Tx: Narcan
    • 6) Avoid use of narcotics in patients on MAOIs--> can cause hyperpyrexic coma
  31. Morphine:
    • 1) analgesia
    • 2) euphoria
    • 3) respiratory depression
    • 4) miosis
    • 5) Side effects:
    • 1- decreased cough
    • 2- constipation
    • 3- histamine release
    • 6) active metabolites can build up in patients with renal failure
  32. Demerol:
    • 1) analgesia
    • 2) euphoria
    • 3) respiratory depression
    • 4) miosis
    • 5) Side effects:
    • 1- tremors
    • 2- fasciculations
    • 3- convulsions
    • 6) no histamine release
    • 7) avoid in patients with renal failure--> can get buildup of normeperidine analogue and result in seizures (also need to be careful with the amount given)
  33. methadone
    stimulates morphine, less euphoria
  34. Fentanyl
    • 1) 80x strength of morphine (does not cross-react in patients with morphine allergy)
    • 2) no histamine release
  35. Sufentanil, alfentanil remifentanil
    very fast-acting narcotics with short half-lives
  36. Benzodiazepines
    • 1) hepatically metabolized
    • 2) Effects:
    • 1- anticonvulsant
    • 2- amnesic
    • 3- anxiolytic
    • 3- respiratory depression
    • 4- not analgesic
  37. Versed (midazolam):
    • 1) short acting
    • 2) contraindicated in pregnancy; crosses placenta
  38. ativan (lorazepam):
    long acting
  39. valium (diazepam)
    long acting
  40. Overdose of benzodiazepines:
    Tx: flumazenil (competitive inhibitor; may cause seizures and arrhythmias; contraindicated in patients with elevated ICP or status epilepticus)
  41. Epidural:
    • 1) causes sympathetic denervation
    • 2) vasodilation
    • 3)
    • Morphine in epidural can cause: respiratory depression
    • Lidocaine in epidural can cause: decreased heart rate and blood pressure
    • 4) dilute concentrations allow sparing of motor function
    • 5) Tx for acute hypotension and bradycardia:
    • 1- turn epidural down
    • 2- fluids
    • 3- phenylephrine
    • 4- atropine
    • 6) T5 epidural can affect cardiac accelerator nerve
    • 7) Epidural contraindicated with:
    • 1- hypertrophic cardiomyopathy
    • 2- cyanotic heart disease--> can get inadvertant spinal anesthesia
  42. Spinal anesthesia
    • 1) injection into subarachnoid space
    • 2) spread determined by baricity and patient position
    • 3) neurologic blockade is above motor blockade
    • 4) Spinal contraindicated with:
    • 1- hypertrophic cardiomyopathy
    • 2- cyanotic heart disease
  43. Caudal block:
    • 1) through sacrum
    • 2) good for pediatric hernias and perianal surgery
  44. Epidural and spinal complications:
    • 1) hypotension
    • 2) headache
    • 3) urinary retention
    • 4) abscess/hematoma formation
    • 5) neurologic impairment
    • 6) High spinal--> respiratory depression
  45. Spinal headaches:
    • Tx:
    • 1) rest
    • 2) increase fluids
    • 3) caffeine
    • 4) analgesics
    • 5) blood patch to site if persists >24 hours
    • 6) headache gets worse sitting up
  46. Perioperative complications (slides to follow):
  47. CHF and renal failure:
    associated with most postoperative hospital mortality
  48. Postop MI:
    • 1) may have no pain or EKG changes
    • 2) can have:
    • 1- hypotension
    • 2- arrhythmias
    • 3- increased filling pressures
    • 4- oliguria
    • 5- bradycardia
  49. Patients who need cardiology workup:
    • 1) angina
    • 2) previous MI
    • 3) shortness of breath
    • 4) CHF
    • 5) walks <2 blocks due to shortness of breath or chest pain
    • 6) FEV1 <70%
    • 7) aortic stenosis murmur
    • 8) PVC >5/min
    • 9) age >70
    • 10) patients undergoing major vascular surgery
  50. ASA Classes:
    • I- healthy
    • II- mild disease without limitation (controlled HTN, obesity, diabetes mellitus, significant smoking history, older age)
    • III- severe disease (angina, previous MI, poorly controlled HTN, diabetes mellitus with complications, moderate COPD)
    • IV- severe constant threat to life (unstable angina, CHF, renal failure, liver failure, severe COPD)
    • V- Moribund (ruptured AAA, sadle pulmonary embolus, ascending aortic dissection resulting in heart failure)
    • VI- donor
    • E- emergency
  51. what risk are most vascular surgeries considered?
    most vascular procedures are considered moderate to high risk surgery
  52. Biggest risk factors for post-op MI:
    • 1) age >70
    • 2) DM
    • 3) previous MI
    • 4) CHF
    • 5) unstable angina
  53. What is the best determinant of esophageal vs tracheal intubation?
    end-tidal CO2
  54. Intubated patient undergoing surgery with sudden transient rise in ETCO2
    • 1) Dx: most likely alveolar hypoventilation
    • 2) Tx: increase tidal volume (most likely due to atelectasis) or increase respiratory rate
  55. Intubated patient with sudden drop in ETCO2
    • 1) likely became disconnected from the vent
    • 2) could also be due to pulmonary embolism or significant hypotension
  56. Where should endotracheal tube be placed?
    should be placed 2cm above the carina
  57. What the most common PACU complication?
    nausea + vomiting

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