Anesthesiology Medication Orientation

Induction Agents:

Propofol: sedative-hypnotic, with enhancement of GABA at its receptors.
Hepatic metabolism. Quick emergence after bolus is related to redistribution. Short half-
life compared to barbiturates. Dose dependant depression of ventilation. No analgesia.
Decreased incidence of nausea seen when run as an infusion. Pain upon injection.
Possibility for bacterial contamination. Dose for induction is 1.5-2.5mg/kg. Infusion rate
for general anesthesia is 100-300 mcg/kg/min.

Thiopental: similar effects as propofol. Redistribution again accounts for prompt emergence after
bolus. Hepatic metabolism. Increased duration of effect with repeat dosing. Dose 3-
5mg/kg. Usually not used as infusion. Used for burst suppression in some neurosurgical
cases.

Etomidate: similar effects as propofol and barbiturates. Pain on injection. Can see myoclonus after
injection. Possibility of adrenal suppression after single bolus or infusions. Minimal
cardiovascular effects after injection. (Not always true). Induction Dose .2-.4mg/kg.

Ketamine: phencyclidine derivative that produce dissociative anesthesia. NMDA antagonist. Has
both analgesic and amnesic qualities. Does not depress ventilation. 1-2 mg/kg.
Emergence delirium, nightmares, Increased ICP. Increased BP and HR, increased oral
secretions. Increased IOP. Used IM to sedation/stun child who needs IV access prior to
surgery, who can or will not take oral versed.

Drug Blood
Pressure
Heart Rate SVR ICP CBF
Propofol
Thiopental
Etomidate
Ketamine

Benzodiazepines: Work to enhance GABA action via a chloride channel. Amnesia, Anxiolysis, sedation.
Minimal CV/Resp effects.

Midazolam: short acting, quick on set. 1-2mg IV. .5mg/kg orally about 30min
Before surgery. Water-soluble.

Lorazepam, Diazepam: Longer acting, build up of propylene glycerol with lorazepam.
Limit use of lorazepam in renal failure patients.


Narcotics: MU receptor agonists. Multiple MU/kappa/delta receptors. Analgesia, respiratory depression.
Nausea/vomiting.

Fentanyl: Synthetic opioid. Potent. Usually does not cause hypotension.
May see decrease in BP when accompanied by benzodiazepines.
Like some of the induction agents, redistribution accounts for short action of effect after
single bolus. Hepatic metabolism p450system. 1-2mcg/kg for analgesia. 2-20mcg/kg for
adjutant to inhalational or intravenous anesthesia.

Hydromorphone: No histamine release, longer acting narcotic. Usual dose 2-.4mg bolus. Also
used in epidural infusions. Onset of action is longer than that of fentanyl. (ie must wait
a bit longer if you do see immediate effect.

Morphine: Histamine release. 1-5mg bolus. Like dilaudid action is slower than fentanyl in onset.

Merperidine: Synthetic opioid . Active metabolites have CNS toxicity and can accumulate with use of
infusions and in patients with renal failure. Used for shivering in the recovery room. Has
some local anesthetic properties. Avoid in patients using MAOI.

Muscle Relaxants:

Depolarizing Muscle Relaxant
Succinylcholine. Associated with increase of .5-1meq of potassium. Triggering agent for MH.
Increased ICP, IOP, intra gastric pressure, and increased LES pressure. Short action 10-15min.
Rapid onset less than one minute.

Non Depolarizing Agents
Vercuronium, Pancuronium, Rocuronium, Atracurium, Mivacurium


Drug Dose Clearance Onset Duration
Succinylcholine 1-2mg IV, 4mg
IM
Pseudo-
cholinesterase
Less than a min 10-15 min

Pancuronium .1mg/kg Renal 3-5 min 60-90 min
Vecuronium .08-1 mg/kg Renal 3-5 min 20-35 min
Rocuronium .6-1.2mg/kg Renal 1-2 min 20-45 min
Atracurium .5mg/kg Hoffman,
Hydrolysis
3-5 min 20-35 min
Mivacurium .25mg/kg Hydrolysis,
Enzymatic
12-20 min 2-3 min

Volatile Anesthetics:
Review in Miller. Agents used for mask induction are Halothane, Sevoflurane.
Desflurane acts quickly and is quickly eliminated when turned off. All of the volatile agents cause
bronchodilation at high levels.


Nitrous Oxide Halothane Isoflurane Desflurane Sevoflurane
Cardiovascular
BP
HR
SVR
CO

NC
NC
NC
NC



NC





NC


NC/

NC/


NC


Respiratory
TV
RR
PaCO2




NC
















Cerebral
CBF
ICP
CMRO
Seizures

Neuromuscular
blockade

Renal
RBF
GFR
UO














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Hepatic
Blood flow

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Metabolism .004% 15-20% .2% <.1% 2-3%
MAC 105-110 .75 1.15 6.0-7.25 2.05


Local Anesthetics:

Concentration: For Local anesthetics 1%=10mg/cc. Hence
.25%bupivicaine=2.5mg/cc. Always read bottles.

Toxic Doses for peripheral blocks: Lidocaine 5mg/kg plain 7mg/kg with epi
Bupivicaine 2mg/kg plain 3mg/kg with epi
Ropivicaine same as bupivicaine

Other Commonly used drugs:

Phenylephrine: direct acting sympathomimetic drug with predominately effects
Making: Standard concentration is 100mcg/ml. Provided as 10mg/cc.
Method 1: dilute 10mg (1cc) into 100cc of .9%saline.
Method 2: 10mg into 9cc saline/water.
Take 1 cc of this mixture (1mg/cc)
And add to another 9cc of saline/water.
Final concentration is .1mg (100mcg)/cc.

Usually see increase in BP, SVR with a decrease in HR.

Ephedrine: Indirect acting sympathomimetic that increases release of NE. has both and effects
(mainly 1 effects). Making: Standard concentration is 5mg/ml. Provided as
50mg/cc. Dilute 1cc (50mg) into 9cc water/saline) final concentration 5mg/ml.
Usually see a increase in BP,HR, SVR

Dopamine: Dose dependant effects. Dopamine at doses of 1-3 mcg/kg/min predominately have
renal effects. Doses of 3-10 mcg/kg/min have more effects (increased contractility)
with only modest increases in blood pressure and pulse. Doses of 10-20mcg/kg min.
Increase BP/pulse. Doses over 20mcg/kg/min have predominately effects.


Norepinephrine: Is an endogenous catecholamine/neurotransmitter with and effects. Increases
SVR. More than .

Epinephrine: Is an endogenous catecholamine with and effects, with more effects on increased
contractility and heart rate, with modest increase in blood pressure. Also has effect on
metabolism effects stimulate lipolysis and liver glycogenolysis and effects inhibit
insulin release; resulting in hyperglycemia. Used with local anesthetics to decrease
absorption of the anesthetic by vasoconstriction. Also used to treat anaphylaxis and
anaphylactoid reactions. Racemic epinephrine used as a nebulized medication to treat
stridor cause by upper airway swelling.

Nitroglycerine: Venodilatation >arteriolar dilatation. Reduces myocardial oxygen consumption.

Nitroprusside: Similar to Nitroglycerine in peripheral dilatation, but has more arterial dilatation than
nitroglycerine. Thiocyanate and cyanide toxicity are possible with high dose infusions
and prolonged use of nitroprusside.

Labetalol: Selective 1 and nonselective receptor antagonists. Less likely to have
bronchospasm than with other nonselective antagonists. Dose is usually 5-10mg
initially. Usually see decrease BP, HR

Esmolol: Selective 1 antagonists.
Dose is usually between 10-30mg initially.
Usually see decrease HR, with some decrease in BP.





Catecholamines MAP HR CO SVR RBF Cardiac
dysrhythmias
Dopamine + + +++ + +++ +
Norepinephrine +++ - - +++ --- +
Epinephrine + ++ ++ ++ -- +++
Dobutamine + + +++ - ++ -


In the OR Events:

I. Preop evaluation / Events
a. Chart review/interview the night before
b. Meet patient in holding prior to surgery
c. Discuss Anesthesia plan with patient
d. Start IV
e. Sedation after patient has been seen by OR nurse and Staff
f. Blocks before surgery

II. OR
a. Assist patient to the OR table
b. Place standard monitors
c. Preoxygenation
d. Induction
e. Mask airway
f. Airway
g. Protect eyes
h. Other monitors
i. Positioning
j. Protection of pressure points

III. End of Case/Emergence/Recovery
a. Return of TOF
b. Reversal of Muscle Relaxation if necessary
c. Antiemetics
d. Spontaneous Ventilation
e. Pain control
f. Extubation
g. Transport to Recovery with Oxygen and monitors
h. Report in Recovery and post op orders

IV. PACU
a. Airway
b. Breathing
c. Circulation
d. Pain control
e. Urine output

Keys for Tables:
MAP=mean arterial pressure
SBP=systolic blood pressure
CBF=cerebral blood flow
ICP=intracranial pressure
SVR=systemic vascular resistance
CO=cardiac output
RBF=renal blood flow
PaCo2=partial pressure arterial carbon dioxide
TV=tidal volume
CMRO=cerebral metabolic rate
RR=respiratory rate
GFR=glomerular filtration rate