CHAPTER 08- ANESTHESIA.txt

• 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)

• 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

• 1) fast
• 2) minimal myocardial depression

• 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

can cause seizures

• 1) good for neurosurgery
• 2) higher cost

• 1) less myocardial depression
• 2) fast onset/offset
• 3) less laryngospasm
• 4) higher cost

• 1) fast acting
• 2) Side effects:
• 1- decreased cerebral blood flow and metabolic rate
• 2- decreased blood pressure

• 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

• 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

• 1) fewer hemodynamic changes; fast acting
• 2) continuous infusions can lead to adrenocortical suppression

• Can be indicated for:
• 1) recent oral intake
• 2) GERD
• 3) delayed gastric emptying
• 4) pregnancy
• 5) bowel obstruction

Diaphragm

neck muscles and face

Depolarizing agent- the only one is 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)

• 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

• 1) undergoes Hoffman degradation
• 2) can be used in liver and renal failure
• 3) histamine release

• 1) fast, short acting
• 2) degradation by plasma cholinesterases
• 3) histamine release

• 1) fast, intermediate acting
• 2) hepatic metabolism

• 1) slow acting, long lasting
• 2) renal metabolism
• 3) most common side effect: tachycardia

• 1) counters nondepolarizing agents
• 2) blocks acetylcholinesterase
• 3) increases acetylcholine

• 1) counters nondepolarizing agents
• 2) blocks acetylcholinesterase
• 3) increases acetylcholine

1) should be given with neostigmine or edrophonium to counteract effects of generalized acetylcholine overdose

• 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)

• (all have an "i" in the first part of the name)
• 1) lidocaine
• 2) bupivicaine
• 3) mepivacaine
• 4) rarely allergic reactions

• 1) tetracaine
• 2) procaine
• 3) cocaine
• Increased allergic reactions secondary to PABA analogue

• 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

• 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

• 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)

stimulates morphine, less euphoria

• 1) 80x strength of morphine (does not cross-react in patients with morphine allergy)
• 2) no histamine release

very fast-acting narcotics with short half-lives

• 1) hepatically metabolized
• 2) Effects:
• 1- anticonvulsant
• 2- amnesic
• 3- anxiolytic
• 3- respiratory depression
• 4- not analgesic

• 1) short acting
• 2) contraindicated in pregnancy; crosses placenta

long acting

long acting

Tx: flumazenil (competitive inhibitor; may cause seizures and arrhythmias; contraindicated in patients with elevated ICP or status epilepticus)

• 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

• 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

• 1) through sacrum
• 2) good for pediatric hernias and perianal surgery

• 1) hypotension
• 2) headache
• 3) urinary retention
• 4) abscess/hematoma formation
• 5) neurologic impairment
• 6) High spinal--> respiratory depression

• 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

associated with most postoperative hospital mortality

• 1) may have no pain or EKG changes
• 2) can have:
• 1- hypotension
• 2- arrhythmias
• 3- increased filling pressures
• 4- oliguria
• 5- bradycardia

• 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

• 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

most vascular procedures are considered moderate to high risk surgery

• 1) age >70
• 2) DM
• 3) previous MI
• 4) CHF
• 5) unstable angina

end-tidal CO₂

• 1) Dx: most likely alveolar hypoventilation
• 2) Tx: increase tidal volume (most likely due to atelectasis) or increase respiratory rate

• 1) likely became disconnected from the vent
• 2) could also be due to pulmonary embolism or significant hypotension

should be placed 2cm above the carina

nausea + vomiting