Phenylephrine (α1 agonist)
ADULT CPR DRUGS Increases systemic vascular resistance only Can cause reflex bradycardia Indications: Isolated intraoperative hypotension.
Ephedrine (α1 and β1 agonist)
ADULT CPR DRUGS Increases systemic vascular resistance AND heart rate Indications: Intraoperative Hypotension with Bradycardia.
Lidocaine 1 mg/kg IV. MAX 3 mg/kg
ADULT CPR DRUGS Indication: Pulseless VT/VF
Magnesium (anti-arrhythmic) 1 mg/kg IV
ADULT CPR DRUGS Indication: Torsades.
Vasopressin (ADH, ↑ water retention, ↑ vasoconstriction) 40 U IV
ADULT CPR DRUGS Indication: Can replace epinephrine for pulseless VT/VF/Asystole/PEA.
Volatile Anesthetics (most to least potent)
Most are bronchodilators, ↑ RR, ↓ TV, eliminated by ventilation, can cause Malignant Hyperthermia.
Nitrous Oxide MAC = 104%
Most are bronchodilators, ↑ RR, ↓ TV, eliminated by ventilation, can cause Malignant Hyperthermia. Dirt Cheap ↓ Volatile anesthetic requirement Least myocardial depression ↑ PVR ↓ FiO2 ↑ PONV Diffuses freely into gas-filled spaces (e.g. contraindicated in pneumothorax/middle ear/bowel surgeries)<br>
Desflurane MAC = 6.0%
Most are bronchodilators, ↑ RR, ↓ TV, eliminated by ventilation, can cause Malignant Hyperthermia. Extremely rapid onset/offset Expensive Stimulates Catecholamine release ↑ N/V Irritating.
Sevoflurane MAC = 2.0%
Most are bronchodilators, ↑ RR, ↓ TV, eliminated by ventilation, can cause Malignant Hyperthermia. Nonirritating so can be used for inhalation induction Extremely rapid onset/offset. Expensive Renal toxicity.
Isoflurane MAC = 1.2%
Most are bronchodilators, ↑ RR, ↓ TV, eliminated by ventilation, can cause Malignant Hyperthermia. Cheap Renal/Hepatic/Coronary/Cerebral blood flow preservation. Lengthy onset/offset irritating.
Halothane MAC= 0.75%
Most are bronchodilators, ↑ RR, ↓ TV, eliminated by ventilation, can cause Malignant Hyperthermia. Cheap nonirritating. Lengthy onset/offset Myocardial Depression sensitizes myocardium to catecholamines Hepatitis.
Opioids (mu-receptor agnoism in brain and spinal cord)
Cause respiratory depression, bradycardia, pinpoint pupils.
Fentanyl Onset: 5 min Duration: Medium Potency:100x Morphine
Cause respiratory depression, bradycardia, pinpoint pupils. Used to blunt stimulation caused by intubation Post-op pain control
Remifentanil Peak time: 90 seconds; Offset: 5 minutes
Cause respiratory depression, bradycardia, pinpoint pupils. Metabolized quickly by plasma esterases Remi drip can be used in lieu of neuromuscular blockers in cases requiring nerve monitoring Used in ENT cases for narcotic wake-up Drip often given with phenylephrine to prevent hypotension Still causes post-op Nausea/Vomiting "Chest wall rigidity" commonly ascribed to remi- but no evidence that it exists
Hydromorphone (Dilaudid) Onset: 10 min/Duration: Long Potency: 8x Morphine No Histamine Release
Cause respiratory depression, bradycardia, pinpoint pupils. Used for post-op PCA.
Morphine Peak time: 90 minutes
Cause respiratory depression, bradycardia, pinpoint pupils. Renally-excreted Histamine Release (causing vasodilation) Urinary retention ↓ GI Motility Triggers chemoreceptor trigger zone → nausea.
Alfentanil Onset: 90 Sec; Duration: Brief
Cause respiratory depression, bradycardia, pinpoint pupils. Most Severe Side Effects
Meperidine (Demerol)
Cause respiratory depression, bradycardia, pinpoint pupils. Side effects: Seizures Anticholinergic Histamine release EuphoriaONLY used for post-op shivering
IV Anesthetics (Most Act through inhibitory GABA neurotransmitters)
All except ketamine cause ↓ SVR, Cardiorespiratory Depression.
Propofol Induction dose: 2 mg/kg; Maintenance Dose: 150 mcg/kg/min
All except ketamine cause ↓ SVR, Cardiorespiratory Depression.Decreases the rate of dissociation of GABA and its receptor Prevents nausea Quick recovery if used as sole anesthetic Neuro: Decreases cerebral metabolic O2 requirements; cerebral blood flow; ICP Pain on injection Supports bacterial growth CV: Greatest myocardial depression Cannot be used 12 hours after drawn.
Etomidate Induction dose: 0.3 mg/kg
All except ketamine cause ↓ SVR, Cardiorespiratory Depression. Least Myocardial Depression Pain on injection Myoclonus Nausea/Vomiting High N/V
Ketamine (NMDA Antagonist) Induction: 1.5 mg/kg
All except ketamine cause ↓ SVR, Cardiorespiratory Depression. Works IV/PO/PR/IM - good choice when IV access not available Stimulation of SNS → good for hypovolemic trauma patients Preserves airway reflexes Dissociative anesthesia with postop hallucinations ↑ ICP ↑ Cerebral O2 demand Stimulation of SNS → Bad for patients with compromised cardiac function Increases airway secretions
Dexmedetomidine (Precedex) (α2 agonist) Loading Dose: 0.75 mcg/kg, Infusion: 0.4 mcg/kg/hr
All except ketamine cause ↓ SVR, Cardiorespiratory Depression. Produces sedation without respiratory depression Used as an adjunct to general anesthesia or for awake intubation
Midazolam (Versed) Increases frequency of chloride channel opening.
All except ketamine cause ↓ SVR, Cardiorespiratory Depression. Premedication to reliever anxiety before general anesthesia Higher doses can cause sedation respiratory depressionCV depression upper airway reflex depression Hypotension Flumazenil is a competitive antagonist that reverses side effects and sedation
Used in induction to relax airway muscles to facilitate intubation.
Rocuronium Fastest onset of NDMBs; intermediate duration
Used in induction to relax airway muscles to facilitate intubation. Most common NDMB at Mt. Sinai.
Vecuronium intermediate onset, intermediate duration
Used in induction to relax airway muscles to facilitate intubation. Dose 0.1mg/kg
Cisatracurium Slow onset; intermediate duration
Used in induction to relax airway muscles to facilitate intubation. Hoffman (non-enzymatic) elimination so attractive choice in liver/renal cases.
Pancuronium Slow onset; long duration
Used in induction to relax airway muscles to facilitate intubation. Tachycardia due to vagolytic effect
Depolarizing Muscle Relaxant
(Persistent depolarization of muscles = cannot be stimulated by Acetylcholine)
Succinylcholine Rapid & Short-Acting, Muscle depolarization causes fasciculations
(Persistent depolarization of muscles = cannot be stimulated by Acetylcholine) Structure = 2 adjoined ACh molecules Metabolized rapidly by pseudocholinesterases Contraindicated in patients at risk for hyperkalemia (burns spinal cord injury muscle dystrophy/disuse) Malignant Hyperthermia Causes myalgias ↑ ICP Myalgias and increased ICP can be prevented by giving a defasciculating dose of roc 3 min prior
Ester-based local anesthetics (Names have only one "i")
Procaine Metabolized by plasma esterases
Ester-based local anesthetics (Names have only one "i") Metabolite is PABA- which can cause allergic reactions
Tetracaine Metabolized by plasma esterases
Ester-based local anesthetics (Names have only one "i") Metabolite is PABA- which can cause allergic reactions
Chloroprocaine Metabolized by plasma esterases
Ester-based local anesthetics (Names have only one "i") Metabolite is PABA- which can cause allergic reactions
Amide-based local anesthetics (Names have at least 2 "i"s)
Lidocaine Metabolized by hepatic enzymes
Amide-based local anesthetics (Names have at least 2 "i"s) Given with epinephrine to minimize systemic toxicity Becomes inactivated in acidic environments (e.g. infected tissue) Give with bicarbonate to reduce "sting" Lidocaine toxicity = CNS excitation (e.g. seizures) then depression (e.g. unconsciousness) cardiovascular depression respiratory depression
Ropivicaine Metabolized by hepatic enzymes
Amide-based local anesthetics (Names have at least 2 "i"s)
Bupivacaine Used for nerve blocks and regional anesthetisa, Liposomal Bupivacaine (Exparel) may help with post-surgical pain.
Amide-based local anesthetics (Names have at least 2 "i"s)
Given with an anticholinergic to block muscaranic side effects.
Neostigmine Shares duration of action with glycopyrolate
Given with an anticholinergic to block muscaranic side effects. Give as reversal only when spontaneous recovery has already started- otherwise it won't work Cholinergic Crisis = SLUD CB2 Salivation Lacrimation Urination Diarrhea Ciliary constriction Bronchospasm Bradycardia
Edrophonium shares duration of action with atropine
Given with an anticholinergic to block muscaranic side effects. Give as reversal only when spontaneous recovery has already started- otherwise it won't work Cholinergic Crisis = SLUD CB2 Salivation Lacrimation Urination Diarrhea Ciliary constriction Bronchospasm Bradycardia
Physostigmine Crosses BBB -> useful for atropine overdose.
Given with an anticholinergic to block muscaranic side effects.
Anticholinergics
Glycopyrolate Given with neostigmine to block muscarinic effects of cholinergic stimulation
Anticholinergics Excellent for treating bradycardia and excess secretions
Antiemetics
Ondansetron (Zofran) 4-8 mg IV 30 min before emergence
Antiemetics5-HT3 Serotonin receptor antagonist More effective at preventing emesis than nausea
Steroids (Dexamethasone) 4-10 mg IV anytime during the case
Antiemetics Cheap and effective Can be given anytime for prolonged PONV relief Risk of hyperglycemia in diabetics
Gastrokinetic (Metoclopramide) 20mg IV before end of case
Antiemetics Dopamine antagonist extrapyramidal side effects avoid in patients with bowel obstruction contraindicated in Parkinson's patients
Butyrophenones (Droperidol, Haloperidol) Haldol 0.5 mg IV at end of case
Antiemetics Central dopamine antagonist Cheap and effective QT prolongation contraindicated in parkinson's patient