1.
A low ____ ___ will markedly delay drug arrival at the site of action.: cardiac output
2.
A patient who is receiving minimal supplemental oxygen and has an acceptable oxygen saturation may have significant ____ ___ ____.: undetected alveolar hypoventilation
3.
A variety of medications are commonly administered during monitored anesthesia care with the desired end points, what are they?: Providing patient comfort, maintaining cardiorespiratory stability, improving operating conditions, & preventing recall of unpleasant perioperative events.
4.
Absence of recall was associated with BIS values below ___.: 80
5.
Advantages of coadministration of small doses of midazolam w/ opioids: Increased patient satisfaction, increased amnesia, decreased N/V, & decreased anxiety.
6.
As the ____ ____ increases, the _____-_____ _____-_____ of all the drugs increases.: infusion duration
context-sensitive half-time
7.
At a minimum, the ___ must be continually displayed and the ___ ____ & ____ at least every ____ ____ during monitored anesthesia care.: ECG
BP measured & recorded
5 minutes
8.
At the present time, no one inhaled or IV drug can provide all the components of monitored anesthesia care (i.e., _____, _____, & _____) with an acceptable margin of safety or ease of titratability. Therefore, patient comfort is usually maintained with a ____ of ____.: analgesia, anxiolysis, & hypnosis
combination of drugs.
9.
Benzodiazepines are commonly used during monitored anesthesia care for their ____, ____, & ____ properties.: anxiolytic, amnestic, & hypnotic
10.
Bone & fat are poorly perfused, & may _____ significant amounts of ______ drugs during _____
administration.
This peripheral depot may contribute to a ___ ____ when the drug is eventually released back into the ____ _____ after its administration is discontinued.: accumulate
lipophilic
prolonged
delayed recovery
central compartment
11.
By acting ______, combinations of drugs enable reductions in the dose requirements of individual drugs.: synergistically
12.
Clinical experience suggests that a level of sedation that allows is _____ ______ optimal for the patient's comfort and safety.: verbal communication
13.
Compare advantages of propofol over benzos: Propofol is noted for the rapid return to clear-headedness, faster recovery & return of psychomotor function
Midazolam is associated w/ prolonged postop sedation & psychomotor impairment
14.
Compare the important properties of midazolam & diazepam: Midazolam: H20 soluble, nonvenoirritant, thrombophlebitis rare, short elimination 1/2 life (1-4h), clearance unaffected by H2 blockers, inactive metabolites, resedation unlikely
Diazepam: lipid soluble, venoirritant, thrombophlebitis, long elimiation 1/2 life (>20 h), clearance reduced by H2 blockers, active metabolites, poss resedation.
15.
Complete recovery of the swallowing reflex occurs approximately ____ ____ after the return of consciousness following propofol anesthesia.: 15 minutes
16.
Cp50: The concentration at which 50% of subjects will fail to respond to a verbal command
17.
Cpss50: The plasma concentration of a drug at steady state that is required to abolish purposeful movement at skin incision in 50% of patients
A measure of potency that is analogous to the familiar parameter of MAC of the volatile inhaled anesthetics.
18.
Describe the advantages of alfentanil over sufentanil: It has a pharmacokinetic advantage for the treatment of discrete stimuli because of its short effect-site equilibration time, which allows rapid access of the drug to the brain & facilitates titration.
19.
Describe the advantages of sufentanil over alfentanil: It has a more favorable recovery profile when used over a longer period because of its shorter context-sensitive half-time.
20.
Describe the pharmacodynamic properties of remifentanil: Predominantly metabolized by nonspecific esterases generating an extremely rapid clearance & offset of effect.
Context-sensitive half-time of 3-5 min
Short effect-site equilibration time (t1/2ke0) of 1.0-1.5 min.
21.
Dexmedetomidine: A selective α2 receptor agonist.
22.
Disadvantages of coadministration of small doses of midazolam w/ opioids: Tendency toward increased respiratory depression, apnea, & excessive
sedation.
23.
Disadvantages of synergistic interactions?: May also extend to the undesirable
interactions of the drugs such as cardiorespiratory depression.
24.
Dose, onset, & duration of IV ketamine: Dose: 0.25-1.0 mg/kg increments
OOA = 1-2 min
DOA = 20-60 min
25.
Dose, onset, & duration of oral ketamine: Dose: 4-6 mg/kg
OOA = 20-30 min
DOA = 60-90 min
26.
During general anesthesia, opioid
requirements to suppress the responses to noxious stimuli are ___ ___ when used as the sole agent
compared w/ when they are used in conjunction w/ a N20/potent inhaled vapor technique.: tenfold higher
27.
During monitored anesthesia care, hyperthermia is still possible as a result of ___ ___ or ___ ___ ____.: thyroid storm or malignant neuroleptic syndrome
28.
During monitored anesthesia care, the maximum benefit of opioid supplementation, in terms
of potentiation of other administered sedatives, will accrue when the opioid is used in the ____ ____ ___. Within this dose range there is great potential for adverse ______ interaction.: analgesic dose range
cardiorespiratory
29.
During the preop assessment for MAC, it is also important to elicit the presence of ______ _______ or _____ _____.: coexisting sensorineural or cognitive deficits.
30.
Effects of MAC on respiratory function: Adverse effects on respiratory drive, directly as a result of sedative-
hypnotic or opioid administration or indirectly as a consequence of brain stem hypoperfusion d/t hypotension (w/ spinals or epidurals).
Marked increases in the WOB d/t increased upper airway resistance.
31.
Effects of mild perioperative hypothermia (i.e., 1 to 2°C) accompanying general
anesthesia: Adverse myocardial outcomes, increased bleeding tendency & transfusion
requirements, wound infections, & delayed
wound healing & hospital discharge.
32.
Following the administration of IV anesthetic drugs, the immediate distribution phase causes a brisk decrease in plasma levels as the drug is transported to the rapidly equilibrating _____-____ ____ of ____. There is a simultaneously occurring distribution of drug to the ____ ____-____ ____ such as ___ & ____.: vessel-rich group of tissues.
less well-perfused tissues
muscle & skin
33.
How does hypercarbia affect the margin of safety for LAs?: By increasing CBF, hypercarbia will increase the amount of LA that is delivered to the brain -> increases the potential for neurotoxicity.
By reducing neuronal axoplasmic pH,
hypercarbia increases the intracellular concentration of the charged, active form of LA ->toxicity.
34.
How does regional anesthesia affect thermoregulation?: Lower extremity vasodilatation causes
central cooling via a redistribution of heat from the core to the periphery. Afferent input to the hypothalamus from
the warm peripheral compartment counteracts conflicting input from the cooling central compartment, which delays the initiation of compensatory thermoregulation.
35.
If the level of sedation is deepened to the extent that ____ ____ is lost, most of the advantages of MAC are lost & the risks of the technique approach those of ____ ____ with an _____ & _____.: verbal communication
general anesthesia
unprotected & uncontrolled airway.
36.
In a single-compartment model, ____ is the only process that can alter drug concentration.: elimination
37.
In contrast to propofol & benzos, what does dexmedetomidine lack?: Amnestic properties at subhypnotic doses
38.
In otherwise healthy adult male volunteers the inhalation of ___% nitrous oxide was associated with marked depression of the swallowing reflex.: 50%
39.
Indications of opioids: Used when regional or LA techniques are inappropriate or ineffective.
Play an important role during the initial injection of LA solution or during other periods of intense patient discomfort.
Pain relief for factors other than the procedure itself, such as uncomfortable
positioning, propofol injection, pneumatic tourniquet pain, or other pain not relieved by the LA technique.
40.
IV administration of 15 mg of diazepam has been shown to depress the swallowing reflex for up to ___ ____.: 4 hours
41.
Ketamine: A phencyclidine derivative
An intense analgesic
Frequently used as a component of
pediatric sedation techniques.
42.
MOA of dexmedetomidine: Stimulation of α2 receptor depresses central sympathetic
function and produces sedation and analgesia.
43.
Propofol has many of the ideal properties of a sedative-hypnotic for use in MAC, what are they?: A context-sensitive half-time that remains short even after infusions of prolonged duration & a short effect-site equilibration time makes it an easily titratable drug w/ an excellent recovery profile. Low incidence of N&V.
44.
Recommended Regimen for the Use of Flumazenil To Antagonize
Benzo Effects: Initial recommended dose of 0.2 mg
If desired LOC isn't achieved in 45 s, repeat 0.2-mg dose
0.2-mg doses may need to be repeated every 60 s until a max of 1 mg is administered
Be aware of the potential for resedation
45.
Remifentanyl infusion rates: Start at 0.1 μg/kg/min ~5 min prior to the 1st painful stimulus. This initial "loading" infusion is then weaned to ~0.05 μg/kg/min to maintain patient comfort.
46.
Risk factors for arterial desaturation: Obesity, pre-existing upper airway
obstruction & respiratory disease, the extremes of age, & the lithotomy position.
47.
Sedation: Sleep w/ preservation of the eyelash reflex & purposeful reaction to verbal or mild physical stimulation
48.
Subhypnotic doses of propofol (a single 10-mg dose in
an adult) possess direct _____ properties.: antiemetic
49.
t1/2ke0 of midazolam: 0.97 to 5.6 minutes
50.
The clinically recognizable effects of local anesthetics on the central nervous system are
concentration-dependent. What symptoms occur as concentrations increase?: Restlessness, vertigo, tinnitus, & difficulty focusing
51.
The clinically recognizable effects of local anesthetics on the central nervous system are
concentration-dependent. What symptoms occur at low concentrations?: Sedation & numbness of the tongue & circumoral tissues & a metallic taste are prominent features.
52.
The combination of _____ & ____
places patients at high risk for developing hypoxemia and apnea.: midazolam & fentanyl
53.
The context-sensitive half-time: The time required for the plasma drug
concentration to decline by 50% after terminating an infusion of a particular duration.
54.
The context-sensitive half-time is not the sole determinant of the
time it takes for the patient to awaken. The time to
awakening is determined in addition by the difference in concentration at the _____ of the _____ and the concentration below which _____ will occur.: end of the procedure
awakening
55.
The effects of initial doses of most drugs in anesthetic practice are terminated by _____, which depends on ____ ____ to redistribution sites.: redistribution
blood flow
56.
The effects of midazolam may recur up to ____ ____ following the
administration of flumazenil.: 90 minutes
57.
The important mechanisms whereby respiratory function may be compromised during MAC include the effects of sedatives & opioids on ____ ____, ____ ___ ____. & ___ ___ _____.: respiratory drive, upper airway patency, & protective airway reflexes.
58.
The pharmacokinetic profile of alfentanil is ideal for the treatment of ____, ____ ____ of ____.: short, discrete episodes of pain.
59.
The swallowing reflex is
significantly depressed for up to ___ ____ following the administration of midazolam despite the return to a normal state of consciousness.: 2 hours
60.
The t1/2ke0 for fentanyl is ____ minutes compared with a t1/2ke0 of ____ minutes for alfentanil.: 6.4
1.1
61.
The upper airway is located outside the thorax. During normal inspiration, the pressure within the upper airway is _____; thus, there is a tendency for the upper airway to ____ under the influence of the surrounding ____ _____.: subatmospheric
collapse
atmospheric pressure
62.
Unlike during opioid-induced sedation, the ____ ____ ____, a feature of natural sleep, appears to be preserved during dexmedetomidine sedation.: hypercapnic arousal response
63.
What are the active metabolites of diazepam?: Desmethyldiazepam & oxazepam
64.
What are the advantages of dexmedetomidine over propofol?: Results in greater sedation, lower BP, & improved analgesia in the recovery room
65.
What are the major thermoregulatory
defenses against hypothermia?: Vasoconstriction, shivering, and behavior.
66.
What do higher concentrations of LAs result in?: Slurred speech & skeletal muscle twitching, which often herald the onset of tonic-clonic seizures
67.
What does ketamine produce?: A dissociative state in which the eyes
remain open w/ a nystagmic gaze.
68.
What does MAC imply?: The potential for a deeper level of sedation than that provided by sedation/analgesia & is always administered by an anesthesiologist provider. The standards for preop eval, intraop monitoring, & the continuous presence of a member of the anesthesia care team, & so forth, are no different from those for general or regional anesthesia
69.
What does MAC usually involve?: The administration of drugs w/ anxiolytic,
hypnotic, analgesic, & amnestic properties, either alone or as a supplement to a local or regional technique.
70.
What does the context-sensitive half-time reflect?: The combined effects of distribution & metabolism on drug disposition.
71.
What does the pulse ox allow?: Continuous real-time monitoring of arterial oxygenation
72.
What drug combination displays marked synergism in producing hypnosis?: Opioids & benzos
73.
What drugs may attenuate the seizures associated with neurotoxicity?: Benzos & barbs
74.
What factors are important
determinants of drug effect and influence the plasma concentration of a drug in a time-dependent fashion?: Redistributive factors
75.
What factors markedly potentiate the cardiovascular toxicity of local anesthetics?: Hypercarbia, acidosis, and hypoxia
76.
What frequently heralds the onset of cardiac arrest?: Cyanosis
77.
What is commonly given w/ ketamine d/t the fear of laryngospasm?: Atropine or glycopyrrolate
78.
What is given along w/ ketamine to reduce the incidence of hallucinations?: Benzos
79.
What is impaired during major conduction anesthesia?: Vasoconstriction & shivering
80.
What is important to evaluate in the preop assessment for a MAC case?: The patient's ability to remain motionless &, if necessary, actively cooperate throughout the procedure.
81.
What is the cause of increased risk of laryngospasm w/ ketamine?: Increased oral secretions
82.
What is the single most vital monitor in the operating room?: A conscientious and well-trained anesthesia caregiver
83.
What may occur during dexmedetomidine administration & why: Hypotension & bradycardia
Administration of α2 agonist is
associated w/ a reduction of sympathetic outflow & an increase in cardiac vagal activity
84.
What occurs over time after the administration of IV anesthetic drugs?: The drug is also distributed to the poorly perfused tissues such as bone & fat.
85.
What should be done to avoid excessive levels of sedation?: Drugs should be titrated in small increments or by adjustable infusions rather than administered in larger doses
according to predetermined notions of efficacy.
86.
When is ketamine avoided in or contraindicated in?: In procedures requiring a completely
motionless patient.
C/I in patients w increased intracranial pressure & w/ glaucoma or open-globe injuries (can elevate ICP & IOP)
87.
When used in small doses (0.25 to 0.5 mg/kg) its use is associated w/
minimal ____ & ___ ____.: respiratory & cardiovascular depression.
88.
Why are continuous infusions superior to intermittent bolus dosing?: Because they produce less fluctuation in drug concentration -> reduced number of episodes of inadequate or excessive sedation
Reduces the total amount of drug administered & facilitates a more prompt recovery.
89.
Why do the doses of benzos need to be reduced in the elderly?: There is a threefold decrease in plasma
concentration of midazolam in an 80-year-old patient compared w/ a 40-year-old patient
