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risks assocated with anesthesia

poor airway management, neuro deficits, preexisitng CAD, administaration at atypical locations (cant be saved fast), not enough pre-testing in hospital

what should the PE focus on?

CVS, lungs, upper airway, peripheral venous sites

what are two types of anesthesia

local and general

what are two classes of local

esters and amides

which local class is better tolerated


what are esters converted to?

PABA: paraaminobenzoic acid: dont use if pt is allergic to sunscreen

cocaine =

local ester

benzocaine =

local ester


local ester

tetracaine =

local ester


local amides

bupivicaine =

local amides

prilocaine =

local amides


on mucous membranes of nose, mouth, tracheobronchial tree and urethra


injection of local anesthetic under the skin

regional block

injection near a nerve or nerve plexus proximal to surgical site


aka subarachnoid block. Anesthetic introduced directly into the spinal fluid

lumbar epidural anesthesia

drug deposited outside the dura, requires more drug than spinal

caudal anesthesia

drug introduced through sacral hiatus above the coccyx, useful for perineal and rectal procedures

IV extremticy block

dilute local anesthetic in IV catheter of limb being operated on

what is the purpose of vasoconstrictor use with ocal anestetics

increases anesthesia time in area; reduces systemic toxicity; increases duration of action

MC vasoconstrictor =


ideal local anestetic =

low systemic toxicity, quick onset of action, solubility in H2O, reversibility

what is MOA of local anestetics

block Na influx at nerve

ADRs of anesthetics

CNS, cardiovascular, respiratory

which local anesthetic has allergic reaction

esters: red, itchy dermatitis

when is cocaine used

topical, ENT surgery

when is benzocaine used

topical, dental

when is procaine used

nerve block and spinal

when is tetracaine used

eye surgery, very toxic, use minimally

what is the MC anesthetic used


what is lidocaine used for

regional nerve block, spinal, also anti-arrhythmic

what is bupivicaine used for

obstetrics, spinal anesthestia

what is used in circumcision?

EMLA cream

what are ideal properties of general anesthetics

1.Rapid loss of consciousness 2. block the reflex reactions to pain; 3.Minimal ADRs 4.Relaxation of skeletal muscle to facilitate endotracheal intubation; 5.not flammable /explosive; 6. Prompt patient recovery

what is balanced anesthesia

multidrug approach to meet all ideal properties

what are stages to general anesthesia

induction, maintenance, recovery

what are stages of depth of anesthesia

stage 1-4: analgesia, excitement, surgical anestheisa, medullary paralysis

what happens in stage 1-


what happens in stage 2 -


what happens in stage 3 - surgical anestheisa

Begins w/ regular respiration and extends to complete cessation of spontaneous respiration; 4 planes: BEST STAGE

what is the ideal plane?

plane 2: stage 3 (no reflexes, breathes on own)

what is the worst stage?

stage 4: pt cant breathe; cardio-respiratory arrest; usually die in operating room

what is the ideal stage

stage 3

what happens in stage 4

medullary paralysis

what is the MOA of general anesthetics

unitary theory: ALL oanesthetics have interactions with lipophilic membranes; cause neuronal failure

what are IV anesthetics

Ultra-Short Acting Barbiturates; Benzodiazepines; Etomidate (Amidate); Propofol (Diprivan); Ketamine ; Opiods; alpha 2 agonists

what are indications of ultra-short acting barbituates

maintenance hypnotics for short surgical procedures; keeps pt out of it

what is ADR of ultra-short acting barbituates

hypnosis/mental cloudiness

what are indications of benzodiazepines

preferred in CARDIAC surgery (no effect on cardio or respiratory); makes pt groggy, feels no pain;

what are ADRs for benzodiazepines

hangover effect

ADR of etomidate

myoclonic muscle movements

propofol indications:

out pt surgery; work quick, short recovery; antiemetic properties (less N,V side effects)

ADR of propofol


ketamine MOA:

dissociate anestheisa: trance like unconsciousness (pt looks awake but is asleep);

special about ketamine:

causes CVS stimulation; can be given IM (good for kids)

opiods : MOA

supplementation to reduce pain

high dose opiod:

high dose, unconciousness w/o CVS depression or HTN; unstable pts

why can alpha 2 adrenergic agonists not be used alone?

inadequate anesthetic depth, bradycardia, hypotension

what is good about inhalation anesthetics?

even though it is acheived slower, there is QUICKER RECOVERY (bc elimnated of lungs)

what are indications of inhalation anesthetics:

usually maintance

minimun alveolar concentraction (MAC)

smallest amount you can give to open alveolus is the amount you want to give

what are two classes on inhaled anestheitcs

gases at room temp; volatile liquids

what is the MC inhalation anesthetic used

nitrous oxide

when is nitrous oxide used (laughing gas)

dental; kids;

what are halogenated hydrocarbons

volatile liquids; potent; last agent; reduces dosage of other medications

example of balanced anesthesia

1. Induction with bolus intravenous anesthetic 2.Supplemental anesthetic (opiod or N20) 3.Neuromuscular blocker (induce paralysis) 4.Reduced concentration of halogenated hydrocarbon

-flurane =

halogenated hydrocarbons

two types of neuromuscular blocking agents

depolarizing blocker, non depolarizing blocker

what are depolarizing blockers

succinylcholine (anectine)

succinylcholine (anectine)

produces neuromuscular block by OVER STIMULATION of nerve; short procedures; no antidote

ADR of succinylcholine

muscle fasiculation

curaiform drugs =

non depolarizing neuromuscular blockers

what is the MOA of non depolarizing neuromuscular blockers

REVERSIBLE COMPETATIVE antagonists of ACH in skeletal muscles; relax muscles

antidote for non depolarizing neuromuscular blockers

acetylcholinesterase inhibitor (stigmine)

selection of pre-op drugs

Relieve anxiety, provide sedation; Induce amnesia; Decrease secretion of saliva and gastric juices; Increase gastric pH; Prevent allergic reactions to anesthetic drugs

selection of anesthesia depends on:

Site of surgery; Positioning of patient on table; Concurrent disease; Elective vs emergency; surgery; Age; Patient preference; Need for pain management post-operatively

A 25 year old woman comes to your office w/ red & itchy dermatitis. She had a dental procedure earlier that day and was administered a local anesthetic. Which drug is the most likely cause of her allergic reaction?

procaine: (ester causes this reaction, used for dental procedures; may also be allergic to sunscreen)

A 77 year-old male is being admitted to the hospital for a coronary bypass. He has been taking Atenolol 100mg PO QD. His anesthetic regimen consisted of: (Propofol induction, Fentanyl IV infusion, Vecuronium muscle relaxant) During the procedure, his HR dropped to 38 and BP to 80/60. It was treated and reversed with atropine and epinephrine. What most likely contributed to this problem?

propofol (causes cardiovascular depression)

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