Anesthesia FINAL EXAM REVIEW

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Horace Wells
pioneer of nitrous oxide
Procaine is also called?
novocaine
What was the goal of procaine (novocaine)
same anesthetic properties of cocaine without the euphoric or addictive properties
protective respose, unique and reported subjectively, experience is influenced by a number of variables, avoidance is strong, unpleasant sensory and emotional experience.
pain
the point at which a sensation starts to be painful to an individual, with resulting discomfort. (varies with individuals)
pain threshold
the neurological experience of pain related to the process of receiving pain stimuli and transmission of this signal to the brain, (same with every individual)
pain perception
the personal interpretation and response to pain message. (highly variable among individuals) also referred to as pain tolerance
pain reaction.
human behavior is driven by unsatisfied needs.
human needs paradigm
studies show that what percentage of adults who are afraid of the dds developed that fear as a child or young person?
50-80%
what is the most effective way to reduce stress?
prevention
what should you do for your patients for stress reduction?
short appt., early morning, mid week, tailor your visits to your pt.
Three main armamentarium components?
-aspirating syringe
-disposable hypodermic needle
-single dose anesthetic cartridge
what does an armentarium facilitate?
-precise amounts
-low risk intravascular injection
-low risk cross contamination
-and numbness :)
ADA Syringe criteria?
-durable, reusable, sterilization
-inexpensive, self contained, light weight, simple use
-effect aspiration with easily observable results.
Different types of LA syringes?
-breech loading, self aspirating, plastic.
anesthetic needs are made of?
stainless steel, sterile, and disposable
-distance from hub to needle tip?
-diameter of needle lumen
-length
-gauge
-red cap needle?
-yellow cap needle?
-blue cap needle? use?
-25 gauge (best b/c thickest)
-27 gauge
-30 gauge (normally pedo only)
average needle lengths for:
-long?
-short?
-ultra short?
-32mm
-20mm
-12mm
according to OSHA recapping or needle removal must be accomplished through the use of?
mechanical device or one handed technique(scoop)
potential needle problems?
-pain
-needle stick
-breakage
contents in an anesthetic cartridge?
-distilled water
-LA drug
-Vasoconstrictor (sulfite preservative)
-sodium chloride (tissue compatibility)
TOTAL CARTRIDGE volume?
2.0mL
TOTAL DRUG volume?
1.8mL
COLORS:
-Lido 2% (plain)
-Lido 2% (1:50000 epi)
-Lido 2% (1:100000 epi)
-Mepivicaine 3%
-Mepivicaine 2% (1:20000 levo)
-Prilocaine 4% (plain)
-Prilocaine 4% 1:200000 epi)
-articaine 4% (1:100000 epi)
-Articaine 4% (1:200000 epi)
-Bupivicaine .5% (1:200000 epi)
-light blue
-green
-red
-tan
-brown
-black
-yellow
-gold
-silver
-Dark blue
cartridge problems?
-bubbles
-extruded stopper
-sticky stopper
-burning on injection
-corroded rusty cap
-leakage
-broken
Central nervous system consists of?
brain and spinal cord
peripheral nervous system consists of?
sensory neurons, 12 cranial nerves, spinal nerves
Process of incoming sensory info FROM THE BODY TO THE CNS
Afferent nerves
Process of outgoing sensory info FROM THE CNS TO THE BODY
Efferent nerves
Afferent and efferent pathways that deal with voluntary and reflexive activities, like skin and teeth sensation with skeletal muscle reaction
somatic nervous system
afferent and efferent pathways that deal with involuntary or automatic activities like smooth muscles, cardiac muscles and glands
Autonomic nervous system
two sections of autonomic nervous system?
Sympathetic and Parasympathetic
fight or flight
sympathetic
rest and digest
parasympathetic
Surrounds a single axon
endoneurium
bundles of axons
fascicles
tissue wrapping fascicle
perineurium
tissue wrapping nerve
epineurium
located in the outer boundary of nerve fiber
mantle bundles
located in the center of the nerve fiber
core bundles
will mantle bundles or core bundles get numb first?
mantle
what produces myelin
schwann cells
Myelin is made up of? hint: %
75% lipid, 20% protein, and 5% carbs
provides insulations, protects and isolates the axon, wraps around the axon, speeds nerve transmissions, prevents external substances (LA example) from diffusing into the nerve, affect with multiple sclerosis
Myelin sheath
LA can only enter the nerve at the?
Nodes of Ranvier
the process where impluses are conducted more rapidly long myelinated nerves (ONLY MYELINATED)
Salatory Conduction
Most numberous fiber in the PERIPHERAL nervous system, NOT myelinated, SLOW conduction, DULL ACHING SENSATION
C fibers
Myelinated nerve fiber, RAPID impulse conduction, SHARP STABBING PAIN
A fibers or A delta
Molecule that has an electric charge is called an
ion
examples of charged ions in a nerve?
NA and K
what types of ION can move through the membrane?
Small, UNCHARGED
What is an uncharged ion called?
neutral base
What state is a nerve in when it receives little to no stimulaton?
Resting
Intracellular has what type of charge?
-negative
Extracellular has what type of charge?
positive
What is the electrical charge inside a cell?
-70mV
Put the following phases in order:
a. firing threshold
b. repolarization
c. resting state
d. rapid depolarization
e. return to resting state
f. slow depolarization
C. resting state
F. Slow depolarization
A. Firing threshold
D. Rapid depolarization
B. Repolarization
E. Return to resting state
What closes off an ion from receiving NA influx?
CA+
A change in electrical charge is called?
Depolarization
slow depolarization occurs until the inside of the cell (Axoplasm) reaches the firing threshold which is?
-50mV
the inability to successfully restimulate he membrane after impulse generation and conduction is called?
refractory state
When the membrane cant be restimulated no matter how great the stimulus
absolute refractory
resting state partially attained, a larger stimulus is required to achieve a firing threshold
relative refractory
Which LA is not available in a dental cartridge?
Procaine
allows nerve membrane to be stable in a water based environment
hydrophillic
keeps water soluble things out like ions
lipophillic
Local anesthetics classifications?
Amides and esters
How are amides and esters defined?
Intermediate chain
-end that allows passage through the cell membrane
-end that gives anesthetic the ability to dissolve in water and keep molecules compatible and stable with tissues
-dictates whether amide or ester which determines the route of metabolism
-lipophillic
-hydrophillic
-Intermediate chain
refers to the actions of a drug on the body
pharmacodynamics
What chemical form is predominately found in the LA cartridge?
RNH+
How does LA equilibrate in the tissues?
dissociating in 3 parts (RNH+, RN, AND H+)
A positively charged molecule is called a?
An uncharged or neutral molecule is called a?
cation
neutral base
something acidic has an abundance of what ions?
H+
A high PKA means?
lower concentration of uncharged base molecules (RN)
The higher the PKA value means what for the onset of LA?
longer
The manner in which the body manages a drug, specifically the mechanisms of absorption, biotransformation, and elimination
Pharmacokenetics
Rate of absorption depends on
-Dose size
-Administration
-vascularity
-vasoconstrictor
LA are peripheral?
vasodialators
less potent vasodialators?
mepivicaine and prilocaine
How do we get LA to stay at a nerve site?
-aspiration
-vasoconstrictors
Two primary routes of biotransformation?
-P450 enzyme in liver
-Pseudocholinesterase enzyme in the blood
Where is LA primarily eliminated?
-Kidney
Amides are biotransformed in the
Liver with P450
Esters are biotransformed in the
blood with pseudocholinesterase
Amides?
lido, prilo, mepivacaine, bupivicaine
Esters?
procaine, most topicals
Prilocaine has some metabolized in the?
lungs
Articaine is a amide BUT is mostly metablized in the
blood
Is CNS or CVS affected first?
CNS
CNS is affected in 2 phases?
1. excitation/irritablility
2.depression
MRD means?
Maximum recommended Dose that can be safely administered in most situations
The rate at which 50% of a drug dose is removed from the systemic circulation
elimination half life
usage of topical targeting mucosal surface only
surface anesthetic
deposition at terminal nerve endings
local infiltrations
deposition near larger nerve branches
field blocks
deposition near major nerve trunks
nerve blocks
Rate of deposition?
one cartridge over 2 minutes
maxillary bone is _______ dense than mandible? and has _______ anatomical variations
less, less
ASA nerve block anesthetizes?
Central, lateral and Canine on inject side
Penetration site for ASA?
Height of mucobuccal fold anterior to canine eminence
Deposition site for ASA
Canine Fossa
MSA nerve block will anesthetize?
max first and second premolars and MB root of the first molar
Penetrations site for MSA?
Height of mucobuccal fold of max second premolar
MSA is missing in __% of people?
68%
Branches into ASA and MSA
IO
trigeminal nerve branches:
V1-
V2-
V3
-Opthalmic
-Maxillary
-Mandibular
small connection of interconnecting vessels
plexus
Pterygoid plexus of veins sits where?
behind the pterygoid muscles and can approximate the max tuberosity
Penetration site for IO?
Height of mucobuccal fold directly over first premolar
Deposition site for IO?
Facial to IO foramen
Penetration site for PSA?
Height of mucobuccal fold superior to DB root of max second molar
Deposition site for PSA?
above and behind the max tuberosity
Angle on PSA?
Upward, inward and backward, 45 degree
Depth for PSA is?
16mm
What injection has the highest risk of post injection hematoma?
PSA
GP point of penetration?
Anterior to the border of the depression of foramen
What concentration of epi can cause necrosis of palatal tissues?
1:50000 epi
AMSA nerve block will anesthetize?
GP, NP, ASA, and MSA
Why is AMSA block popular?
Cosmetic, prevents labial droop
Long acting anesthetic?
bupivacaine with epi
May be used cautiously?
No use in any circumstance?
-relative contraindication
-absolute contraindication
What replaced procaine?
lido in 1943
What is currently the gold standard in Dentistry?
Lido
Other names for lido?
xylocaine, alphacaine, lignospan, and octocaine
MRD for lido?
2mg/lb or 300mg
Is lido an effective topical anesthetic?
yes
MRD for mepivacaine
2.0mg/lb or 300mg
Other names for mepivacaine?
polocaine and carbocaine
Other names for prilocaine?
citanest and citanest forte
MRD for prilocaine?
2.7mg/lb or 400mg
the metabolites in prilocaine are called? these can cause?
ortholuidine and methemoglobinemia
Other names for articaine?
septocaine or articadent
MRD for articaine?
3.2mg.lb or 500mg absolute MRD
Total drug volume in a cartridge of articaine?
1.7mL
Nerve damage that may be defined as a partial or complete loss of sensation
paresthesia
articaine can also cause what in large doses?
methemoglobinemia
Why is articaines metabolism so unique?
mostly metabolized like an ester in the blood even though its an amide
What is the best LA choice for a patient with liver issues?
articaine
Most toxic and most potent anesthetic?
Bupivacaine
Other name for Bupivacaine?
mepivacaine
MRD for bupivacaine
.6mg/lb or 90mg
amount of LA per cartridge
2%-
3%-
4%-
4% articaine-
.5%-
-36mg
-54mg
-72mg
-68mg
-9mg
amount of vasoconstrictor per cartridge
1:20 levo-
1:50 epi-
1:100 epi-
1:200 epi-
-.09
-.036
-.018
-.009
MRD of Vasoconstrictor for Cardiac patients?
healthy?
-.04
-.2
Most vasodialating anesthetic?
Least?
-procaine but not used any more so bupivacaine
-mepivacaine
Where is epi secreted?
adrenal glands
What does epi do?
-constricts vessels
-increases HR
-dialates lungs and pupils
-relaxes bladder
What medical conditions are concerning with vasoconstrictors?
-Cardiac and hyperthyroidism
Two receptor types for epi
Alpha and beta
Extends the shelf life of the epinephrine
Bisulfite preservative
Allergy worry? and may cause burning upon injection?
Bisulfite preservative
- Diabetics that have a hard time secreting enough insulin
-Diabetics that have a hard time shuttling blood sugars into body tissues
-type I
-type II
Epi stimulates the liver to?
produce more blood sugars
Epi is recycled in?
Whatever is not recycled becomes?
Furthbreakdown is called?
-synaptic junctions all over the body
-COMT
-MAO
Levo has __ the potency of epi and requires __ the concetration
1/6, 5x
Levo affects __% of alpha receptors and __% of beta
75%, 25%
MRD for LEVO?
1.0mg healthy and .2mg for cardiac
Most common ingredient in topical?
benzocaine
Depth that topical anesthetic reaches in the mucosa?
3mm
What is possible with benzocaine topical? so look out for?
-methemoglobinemia
-sprays
EMLA means?
Eutectic mixtures of Local Anesthetics
Nitrous is stored in what color containers?
stored as?
blue
liquid under pressure but administered as gas
Pressure gauge is ___ a realiable indicator for what is in the tank?
not
O2 is stored in what color container?
stored as? administered as?
green
gas, gas
Full tank of O2 is?
2000-2100 psi
Nitrous is a CNS ____________?
Depressant
How is Nitrous Metabolized?
its not
Stages of anethesia:
1-
2-
3-
4-
1-analgesia (3 sub stages)
2-delirium/excitatory
3-surgical (4 sub stages)
4- surgical w/ respiratory paralysis
At what stage has you OVERSEDATED?
stage 3 b/c of loss of consciousness
Relative contraindications for Nitrous?
pregnancy, communication barriers, nasal obstruction, epilepsy, emotional instability, and fear or complusive personalities
two types of nitrous systems?
central and portable
adding medication/gas in small increments until desired effects are achieved
titration
volume of air in one breath
tidal volume
calc of nitrous oxide
l/min of nitrous over tidal volume
Medications used at the same time
Concomitant
What medication is contraindicated with tricyclic antidepressants?
levo
What medication is contraindicated with beta blockers?
epi
medications for congestive heart failure? avoid?
digitalis, epi
medications for psychotic disorders? avoid?
phenothiazides, epi
Absolutes contraindications for cardiovascular disease?
-bp 200/115
-6 mos of MI or CVA or coronary bypass
-uncontrolled angina pectoris
-dysrhythmias
What is the absolute contraindication for vasoconstrictors?
uncontrolled hyperthyroidism
What dose should we use with controlled hyperthyroidism?
.04 cardiac
asthmatics are at risk for?
allergy to bisulfite preservative
what is the tx for methemoglobinemia?
methylene blue
-temporary stroke/clot in the CNS
-Temporary stroke/close in the CVS
-TIA
-CVA
Best time for tx when pregnant?
2nd trimester
Most abused form of narcotic in the U.S
oxycodone
most prescribed opiate in the U.S
Hydrocodone
When anesthetizing the IA nerve you typically numb what other nerve?
lingual
Penetration site for IA
slight lateral to pterygomandibular raphe, 2-3, superior to the greatest concavity of the coronoid notch
deposition site for IA
1mm lateral to medial aspect of ramus above the mandibular foramen
2nd most at risk for hematomas?
IA
Penetration site for buccal?
Buccal fold just distal and buccal to the most posterior molar
percutaneous injury or contact of mucous membrane or non intact skin with blood saliva tissue or other body fluids that are potentially infectious
occupational exposure
penetration site for mental and incisive nerves?
depth of mucobuccal fold superior to mental foramen, generally near the premolars.
What block is considered a true mandibular block?
Gow gates
Gow gates will anesthetize?
IA, LB, MENTAL, INCISIVE, LINGUAL, MYLOHYOID and others
-wide open mouth mandibular block
-closed mouth
-gow gates
-vazirani-akinosi
ABC stands for?
Airway, breathing, circulation
most common medical emergency in dentistry?
vasodepressor syncope
What is the second leading cause of unconsciousness after syncope?
postural hypotension
When should you not give a patient nitroglycerin for chest pain?
when they are hypotensive
Treatment for anaphylaxis?
immediate dose of .3-.5mg epi 1:1000 given IM or under tongue