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What is the benefit of giving Fentanyl and Morphine together at the beginning of the case?
Different rates of metabolism so you have a sustained therapeutic effect with little risk of narcotic overdose while trying to extubate
What is the goal of pre-op medication?
ensure the patient is anxiety and pain free
What must you do PRIOR to administering anything pre-op?
Make sure consent and patient ID are completed, and the patient has met the surgeon
What is the therapeutic effect of a benzodiazepine?
relief of anxiety, sedation, amnesia
What is the class and standard dose of Midazolam?
What is the class and standard dose of Diazepam?
- 5-10 mg IV or PO
What is the class and standard dose of Lorazepam?
- 0.5-2 mg IV or PO
What is an absolute contraindication to administration of benzodiazepines?
No urine pregnancy test in someone of childbearing years
What are the 2 disadvantages to benzodiazepines?
- 1) excessive/prolonged sedation in elderly
- 2) may interfere with release of cortisol in response to stress
What is the therapeutic effect of an opioid?
What is the class and standard dose for Fentanyl?
What is the class and standard dose for morphine?
What is the class of dilaudid?
What is the class of demerol?
What are the 6 disadvantages of opioids?
- 1) resp depression (increased CO2 threshold)
- 2) orthostatic BP
- 3) N/V
- 4) delayed gastric emptying (PO med metabolism, increased risk of n/v/aspiration)
- 5) biliary tract spasm (difficult for ERCP)
- 6) itching
What is the primary therapeutic effect of anicholingergics?
- 1) antisialagogue (less saliva)
- 2) prevention of reflex bradycardia
- 3) sedative/amnestic - EXCEPT glycopyrolate
What is the class and standard dose of atropine?
What is the class and standard dose for glycopyrrolate?
Should you use anticholinergics routinely?
No - best for risks you can foresee and oral/prone/supine cases
Why is an anticholinergic beneficial when using propofol for induction?
What are the most common side effects (3) of anticholinergics?
- CNS suppression
- increased body temp
How does and anticholinergic work?
competitively binds with muscarinic receptors in the CNS = no acetylcholine binding
What is the primary goal of Bicitra? and how is it different?
- Goal is to elevate pH of stomach contents (so they are less caustic if aspirated)
- works IMMEDIATELY - treats what is currently in the stomach
What is the class and dose of Bicitra?
Is Bicitra used for every case?
No - only high aspiration risk cases
What is the class, therapeutic effect, and dose of famotidine?
- h2 antagonist
- reduces pH of gastric contents being secreted (future - not what is currently there)
- 20-40 mg PO
What is the class, therapeutic effect, and dose of pantaprazole?
- proton pump inhibitor
- increase gastric pH by suppression over the course of several hours
- 40 mg IV
what is the class, therapeutic effect, dose of omeprazole?
- proton pump inhibitor
- reduces acid secreted over next several hours
- 20 mg PO
What is the therapeutic effect of GI pro kinetics?
- decrease gastric fluid volume
- reduce n/v
- reduces risk of aspiration
What is the class and dose of metoclopramide? how does it work (3 mechanisms)?
- GI prokinetic
- 10 mg IV, PO
- Increases gastric motility, increases LES sphincter tone, decreases pyloric sphincter tone
Who would you NOT give metoclopramide to?
- Parkinsons - levodopa
- bowel obstruction
What is the therapeutic effect of alpha2 agonists?
decreases SNS responses
What is the class and dose of clonidine?
Who requires triple treatment for aspiration prevention? what does it include?
- high risk patients
- bicitra, pepcid, reglan
What is the mechanism of action for Thiopental?
depression of the Reticular Activating System (via inhibition of GABA)
What is the dose and duration of Thiopental?
If you have a CVP port and LR infusing via a separate port, where will you push Thiopental? why?
CVP - thiopental + LR creates a precipitate
Can you push Thiopental and Vecuronium back to back?
No - creates precipitate
What is the mechanism of action of Propofol?
inhibitory transmission mediated by GABA
What is the induction dose for propofol? maintenance dose? duration?
- Induction: 2 mg/kg
- Maintenance: 100-200 mcg/kg/min (hypnosis), 25-70 mcg/kg/min (sedation)
- Duration: 5-10 mins
Who can NOT receive propofol?
What is the mechanism of action for Etomidate?
binds to subunit of GABA (increases affinity of GABA) --> depression of RAS
What is the dose and duration of Etomidate?
- dose: 0.25 mg/kg
- duration: 3-12 minutes
What should you co-administer with etomidate? why?
a muscle relaxant - may cause myoclonus
What is the Mechanism of Action of Methohexital?
depression of RAS (via enhanced transmission of inhibitory neurotransmitters such as GABA)
What is the dose of methohexital? duration?
- dose: 2mg/kg
- duration: 5-10 mins
What type of NMB agent is Succinylcholine?
What is the dose of succinylcholine? the onset? the duration?
- dose: 1 mg/kg
- onset: 1 minute
- duration: less than 10 mins
What 4 things does succinylcholine increase?
- 1: intraoccular pressure
- 2: intragastric pressure
- 3: intracranial pressure
- 4: serum potassium levels (0.5-2 pts)
What are the 4 M's of succinylcholine?
- 1: Malignant Hyperthermia (masseter muscle rigidity is sign)
- 2: Myalgia's
- 3: Myocardium (muscarinic bradycardia)
- 4: Myopathies (Duchenne's dystrophy)
What type of NMB is vecuronium?
What is the intubation dose, onset, and duration of vecuronium?
- dose: 0.1 mg/kg
- onset: 2-3 mins
- duration: 45-90 mins
What is so great about vecuronium?
very predictable re-dosing
What type of NMB is rocuronium?
What is the intubation dose, onset, and duration of rocuronium?
- dose: 1 mg/kg (0.45-1.2)
- onset: 1.5 minutes
- duration: 35-75 minutes
What does Sugammadex do?
What type of NMB is cisatracuruim?
What is the intubation dose, onset, and duration for cisatracuruim?
- dose: 0.2 mg/kg
- onset: 2-3 minutes
- duaration: 40-75 minutes
What is an advantage of using cisatracuruim?
cleared via spontaneous nonenzymatic breakdown - not dependent upon ANY organ system
What is the MAC for N2O (nitrous oxide)?
What 2 populations should you NOT use N2O?
- 1: pregnancy
- 2: suspected air pockets (air embolism, pneumothorax, intestinal obstruction, intracranial air)
What is the MAC for isoflurane?
What are 2 risks with isoflurane?
- 1: dilates coronary arteries so may "steal" blood from stenotic fixed arteries
- 2: >1% = increased ICP d/t vasodilation
Will you need more or less non depolarizing NMB when using isoflurane?
What is the MAC of desflurane?
How does the wake up time of desflurane compare to isoflurane?
wake up times are 50% less
What is the MAC of sevoflurane?
Is sevoflurane rapid or slow in re: uptake and elimination?
Does sevoflurane make pediatric cases more or less difficult? why?
nonpungent, relaxes enough for intubation
What must you always administer with sevoflurane? why?
2 liters fresh gas - may cause nephrotoxic compound A
Why are anticholinesterases given?
to "reverse" a non-depolarizing NMB - prevents the breakdown of ACh which allows more available to competitively knock NMB of post synaptic receptor
What is neostigmine?
What is the dose, onset, and duration of neostigmine?
- dose: 0.05 mg/kg (max EVER is 5mg)
- onset: 5-10 mins
- duration: 1 hour
Why do we give an anticholinergic with neostigmine?
flooding of cholinergic receptors can produce bradycardia to the point of asystole