question

Propofol (induction dose)

answer

1-2.5 mg/kg

question

Propofol (maintenance)

answer

100-200 mcg/kg/min

question

Propofol (conscious sedation)

answer

25-75 mcg/kg/min

question

Propofol (onset)

answer

30 seconds

question

Propofol (duration)

answer

3-8 minutes

question

Etomidate (induction dose)

answer

0.2-0.6 mg/kg

question

Etomidate (onset)

answer

30-60 seconds

question

Etomidate (duration)

answer

3-5 minutes

question

Lidocaine (induction dose)

answer

1.5 mg/kg

question

Lidocaine (max LA dose w/out Epi)

answer

4 mg/kg

question

Lidocaine (max LA dose w/ Epi)

answer

7 mg/kg

question

Ketamine (IV dose induction)

answer

2-4 mg/kg

question

Ketamine (PO)

answer

10mg/kg

question

Ketamine (IV infusion or iv push)

answer

15-45 mcg/kg/min (1-3 mg/min infusion) 0.5-1.0 mg/kg iv

question

Ketamine (IM dose)

answer

4-6 mg/kg

question

Ketamine (IV onset)

answer

1-2 minutes

question

Ketamine (IM onset)

answer

3-8 minutes

question

Ketamine (IV duration)

answer

6-15 minutes

question

Ketamine (IM duration)

answer

15-20 minutes

question

Ketamine (conscious sedation)

answer

0.25-0.5 mg/kg IV

question

Succinylcholine (IV onset)

answer

30-60 seconds

question

Succinylcholine (IM onset)

answer

2-3 minutes

question

Succinylcholine (IV duration)

answer

3-5 minutes

question

Succinylcholine (IM duration)

answer

10-30 minutes

question

Succinylcholine (IV induction)

answer

1-1.5 mg/kg

question

Succinylcholine (IM dose)

answer

3 mg/kg

question

Succinylcholine (laryngospasm dose)

answer

20 mg IV

question

Vecuronium (IV induction)

answer

0.1 mg/kg

question

Vecuronium (Maintenance gtt)

answer

1 mcg/kg/min

question

Vecuronium (onset)

answer

2-4 minutes

question

Vecuronium (duration)

answer

30-60 minutes

question

Cisatracurium (duration)

answer

30-60 minutes

question

Cisatracurium (onset)

answer

2-4 minutes

question

Cisastracurium (IV induction)

answer

0.1 mg/kg

question

Cisastracurium (maintenance)

answer

1-3 mcg/kg/min

question

Rocuronium (induction dose)

answer

0.6-1.2 mg/kg

question

Rocuronium (maintenance)

answer

5-12 mcg/kg/min

question

Rocuronium (duration)

answer

30-60 minutes

question

Rocuronium (onset)

answer

60-90 seconds

question

Atracurium (induction)

answer

0.5 mg/kg

question

Atracurium (duration)

answer

30-60 minutes

question

Atracurium (maintenance)

answer

3-5 mcg/kg/min

question

Atracurium (onset)

answer

2-4 minutes

question

Ofirmev (dose)

answer

1000mg q6 or 650mg q4 infused over 15 minutes. Max daily dose 4000mg

question

Ofirmev (onset/peak/duration)

answer

10 minutes/ 1hr/ 4-6 hours

question

Hydrocortisone (dose)

answer

250mg IV

question

Scopolamine (IV/IM dose)

answer

0.3- 0.6 IV/IM

question

Scopolamine Patch (dose/onset/ duration)

answer

1.5mg total dosage for patch; 4 hours/ 3 days

question

Scopolamine (onset IV)

answer

8-10 minutes

question

Scopolamine (onset IM)

answer

30 minutes

question

Scopolamine (duration IV)

answer

2 hours

question

Scopolamine (duration IM)

answer

4 hours

question

Dopamine (onset)

answer

5 minutes

question

Dopamine (duration)

answer

minutes after discontinuing

question

Dopamine (dosing)

answer

1-70 mcg/kg/min (Only dopaminergic receptors stimulated at less than 2 mcg/kg/min, Beta at 2-5 mcg/kg/min, Alpha at rates greater than 10 mcg/kg/min)

question

Phenylephrine (bolus dose)

answer

50-100 mcg/dose (do not exceed 0.5mg in adults)

question

Phenylephrine (duration)

answer

10-15 minutes

question

Phenylephrine (onset)

answer

immediate

question

Clonidine (dose)

answer

0.1-0.6 mg (in 2 or 3 dose orally)

question

Precedex (loading dose)

answer

1 mcg/kg IV over 10 minutes

question

Precedex (Maintenance Drip)

answer

0.2-1.4 mcg/kg/hr

question

Precedex (fiberoptic intubation)

answer

0.7 mcg/kg/hr

question

Precedex (procedural sedation)

answer

start 0.6 mcg/kg/hr and titrate

question

Precedex (duration)

answer

10-30 min after infusion stops

question

Precedex (onset)

answer

10-20 minutes

question

Nitroglycerine (dose)

answer

25-50 mcg IV bolus 5-200 mcg/min IV infusion (200= max dose) 0.4 mg SL q5 x 3 doses

question

Nitroglycerine (duration)

answer

3-5 minutes

question

Nitroglycerine (onset)

answer

1 minute

question

Hydralazine (dose)

answer

2.5- 20mg IV (5-10mg q20 with a max dose of 40mg)

question

Hydralazine (duration)

answer

4-8 hours

question

Hydralazine (onset)

answer

15-20 minutes

question

Labetalol/ Trandate (non-selective) IV intermittent dose

answer

0.25mg/kg

question

Labetalol/ Trandate (non-selective) Infusion dose

answer

up to 2 mg/min

question

Labetalol/ Trandate (non-selective) IV bolus dose

answer

20mg-80mg q10 (start with 20 and work up 300mg max)

question

Labetalol (duration)

answer

2-4 hours

question

Labetalol/Trandate (onset)

answer

immediately

question

Metoprolol/Lopressor (dose)

answer

(selective) 2.5 to 5mg q5 max dose 15mg

question

Metoprolol/Lopressor (duration)

answer

(selective) 5-8 hours

question

Metoprolol/ Lopressor (onset)

answer

immediately

question

Esmolol/ Brevibloc (onset)

answer

(selective) 1-2 minutes

question

Esmolol/ Brevibloc (duration)

answer

(selective) 5-10 minutes

question

Esmolol/ Brevibloc (bolus and infusion dose)

answer

(selective) Bolus 10-15 mg Infusion: 25-350 mcg/kg/min (loading dose of 500mcg/kg/min for 1 min then titrate)

question

Propanolol/ Inderal (dose)

answer

(non selective) IV 1mg q5 minutes up to 5mg

question

Propanolol/Inderal (onset)

answer

(non selective) 15 minutes

question

Propanolol/Inderal (duration)

answer

6 hours

question

Epinephrine (onset)

answer

less than a minute

question

Epinephrine (duration)

answer

5-10 minutes

question

Epinephrine (peak)

answer

1-2 minutes

question

Epinephrine (iv push)

answer

10-100mcg

question

Epinephrine (Infusion)

answer

0.01-0.03 mcg/kg/min (Beta) 0.03-0.15 mcg/kg/min (alpha and beta) 0.15-0.3 mcg/kg/min (alpha

question

Norepinephrine (infusion dose)

answer

0.01-0.2 mcg/kg/min

question

Norepinephrine (onset)

answer

less than 1 minute

question

Norepinephrine (duration)

answer

2-10 minutes

question

Norepinephrine (peak)

answer

1-2 minutes

question

Albuterol/ Proventil/ Ventolin (dose)

answer

90 mcg/inhalation 2 puff MDI q4-6 hours 2.5mg neb q4-6 hours

question

Albuterol/ Proventil/ Ventolin (duration)

answer

6-12 hours

question

Albuterol/ Proventil/ Ventolin (onset)

answer

15-30 minutes

question

Zofran (dose)

answer

4-8mg IV (0.15mg/kg)

question

Zofran (duration)

answer

4-8 hours

question

Zofran (onset)

answer

rapid

question

Granisetron (Kytril; IV and PO dose)

answer

1 mg IV 2 mg PO

question

Promethazine (dose)

answer

12.5-25 mg IV 6.25mg/5ml PO

question

Promethazine (duration)

answer

4-12 hours

question

Promethazine (onset)

answer

3-5 minutes

question

Metoclopramide (dose)

answer

10-20mg IV

question

Metoclopramide (duration)

answer

1-2 hours

question

Metoclopramide (onset)

answer

1-3 minutes

question

Ranitidine (dose)

answer

50-100 mg IV (1-2.5 mg/kg) 150-300 PO

question

Flumazenil (dose)

answer

0.2 mg/kg (slow titration max 3mg)

question

Flumazenil (onset)

answer

1-2 minutes

question

Flumazenil (duration)

answer

45-90 minutes

question

Benadryl (dose)

answer

25-50mg (PO/IV/IM) (0.5-1.5mg/kg)

question

Benadryl (duration)

answer

3-6 hours

question

Dexamethasone (dose)

answer

5-10mg

question

Dexamethasone (duration)

answer

variable

question

Dexamethasone (onset)

answer

1 hour

question

Naloxone (dose)

answer

40-100 mcg

question

Naloxone (duration)

answer

20-60 minutes

question

Naloxone (onset)

answer

2 minutes

question

Ketoralac (dose)

answer

30 or 60mg

question

Ketoralac (duration)

answer

4-6 hours

question

Ketoralac (onset)

answer

30 minutes

question

Indigo Carmine

answer

(40mg/5ml vial) 5mg

question

Furosemide (dose)

answer

20-40mg IV (up to 200mg/dose for acute pulmonary edema) 20-80mg PO (qday or q6-8 hrs for edema, HTN; not to exceed 600mg/day)

question

Lasix (duration)

answer

2 hours IV 6-8 hours PO

question

Lasix (onset)

answer

5 min IV 30 min IM 30-60 min PO/SL

question

Lasix (peak)

answer

<15min IV 1-2 hours PO/SL

question

Oxytocin (dose)

answer

0.5-8 mU/min

question

Hemabate/ Carboprost tromethamine (dose)

answer

250mcg IM initial repeat PRN q 1.5-3.5 hours

question

Methergine/ Methylergonovine (dose)

answer

0.2 mg IM q2-4 (not to exceed 5 doses) (Then 0.2-0.4 mg PO q6-8 hours for 2-7 days)

question

Sublimaze/Fentanyl (IV dose)

answer

25-100mcg

question

Sublimaze/Fentanyl (IV duration)

answer

0.5-1 hour

question

Fentanyl (peak)

answer

20-30 minutes

question

Sublimaze/Fentanyl (IV onset)

answer

2-5 minutes

question

Hydromorphone (IV onset)

answer

15-30 minutes

question

Hydromorphone (IV duration)

answer

4-5 hours

question

Hydromorphone (IV dose)

answer

0.25 mg -1mg

question

Hydromorphone (peak)

answer

30-90 minutes

question

Morphine (IV dose)

answer

2-10mg

question

Morphine (IV duration)

answer

4-5 hours

question

Morphine (IV onset)

answer

20 minutes

question

Morphine (IV peak)

answer

30-60 minutes

question

Sufentanil (IV dose)

answer

0.5 mcg/kg

question

Sufentanil (IV onset)

answer

1-3 minutes

question

Sufentanil (IV duration)

answer

dose dependent

question

Remifentanil (IV induction and infusion dose)

answer

0.5-1 mcg/kg (induction) 0.05-2 mcg/kg/min (infusion)

question

Remifentanil (IV onset)

answer

1 minute

question

Remifentanil (IV duration)

answer

5-10 minute

question

Remifentanil (peak)

answer

1 minute

question

Midazolam (onset)

answer

IV 1-2 minutes IM 15 minutes PO 30 minutes

question

Midazolam (duration)

answer

IV 20-50 minutes IM up to 6 hours

question

Midazolam (IM, IV, Induction dose)

answer

IM 0.07 mg/kg IV 0.02-0.03 mg/kg Induction 0.1-0.2 mg/kg

question

Edrophonium (dose)

answer

0.05-0.1 mg/kg

question

Edrophonium (duration)

answer

30-60 minutes

question

Edrophonium (onset)

answer

5-10 minutes

question

Atropine (dose)

answer

0.4-1mg IV (bradycardia) (NMB Reversal 10 mcg/kg with edrophonium 0.02 mg/kg peds)

question

Atropine (duration)

answer

2-6 hours

question

Atropine (onset)

answer

30-60 seconds

question

Neostigmine (dose)

answer

0.05 mg/kg max dose 5mg (w/ robinul 0.2mg for every 1 mg of neostig)

question

Neostigmine (duration)

answer

45-90 minutes

question

Neostigmine (onset)

answer

5-15 minutes

question

Glycopyrrolate (dose)

answer

IV 0.1-0.2 mg for bradycardia 0.2 mg for every 1mg of neostig or 10 mcg/kg

question

Glycopyrrolate (onset)

answer

1-3 minutes

question

Glycopyrrolate (duration)

answer

Vagal effects about 2 hours, decreased salivation for 7 hours

question

Vasopressin (dose)

answer

Bolus 10-20 units 0.04-0.1 unit/min

question

Vasopressin (duration)

answer

10-30 minutes

question

Vasopressin (onset)

answer

1-5 minutes

question

Vasopressin (peak)

answer

5 minutes

question

Ephedrine (dose)

answer

5-10mg

question

Ephedrine (onset)

answer

less than 1 minute

question

Ephedrine (duration)

answer

10- 60 minutes

question

Atracurium

answer

0.5 mg/kg

question

Succinylcholine induction dose

answer

0.5-1 mg/kg RSI: 1-1.5 mg/kg

question

Succinylcholine onset

answer

30 sec

question

Succinylcholine duration

answer

4-6 min

question

Succinylcholine MOA

answer

binds to nicotinic ACh receptors at the NMJ causing depolarization

question

Rocuronium induction dose

answer

o.6-1.2 mg/kg

question

Rocuronium onset

answer

45-90 sec

question

Rocuronium duration

answer

15-150 min

question

Non-depolarizing NMBA MOA

answer

competitive binding of nicotinic ACh receptors at the NMJ, preventing depolarization

question

Cisatracurium induction dose

answer

0.2 mg/kg

question

Cisatracurium onset

answer

90-120

question

Cisatracurium duration

answer

20-40 min

question

Fentanyl dose

answer

50-150 mcg

question

Fentanyl onset

answer

within 30 sec

question

Fentanyl peak

answer

3-5 min (6.8 min)

question

Fentanyl duration

answer

30-60 min

question

Fentanyl MOA

answer

Mu 1&2 agonist

question

Fentanyl issues

answer

muscle rigidity, bradycardia w/large dose, potency 100x morphine

question

Remifentanil dose

answer

0.05-2 mcg/kg/min

question

Remifentanil onset

answer

within 30 sec

question

Remifentanil peak

answer

3-5 min

question

Remifentanil duration

answer

5-10 min

question

Remifentanil metabolism

answer

plasma cholinesterases

question

Dilaudid dose

answer

0.5-2 mg

question

Dilaudid onset

answer

almost immediate

question

Dilaudid peak

answer

5-20 min

question

Dilaudid duration

answer

2-4 hrs

question

Dilaudid issues

answer

muscle rigidity

question

Morphine dose

answer

1-15 mg

question

Morphine onset

answer

<1 min

question

Morphine peak

answer

5-20 min

question

Morphine duration

answer

2-7 hrs

question

Morphine issues

answer

avoid in asthma and hypotension because of histamine release

question

Propofol dose

answer

1-2 mg/kg

question

Propofol maintenance dose

answer

50-150 mcg/kg/min

question

Propofol onset

answer

30 sec

question

Propofol peak

answer

1 min

question

Propofol duration

answer

5-10 min

question

Propofol MOA

answer

increasing the duration of the GABA-activated opening of the chloride channel with resulting hyperpolarization of cell membranes

question

Propofol properties & issues

answer

anti-emetic hypotension, irritation on injection

question

Ketamine dose

answer

0.5-1 mg/kg

question

Ketamine onset

answer

<30 sec

question

Ketamine peak

answer

1 min

question

Ketamine duration

answer

5-15 min

question

Ketamine MOA

answer

inhibits glutamate @ the NMDA receptor

question

Ketamine metabolism

answer

cytochrome P450 system

question

Ketamine S/E

answer

++ MAP, ++ HR, + CO, no respiratory depression, bronchodilation, analgesic properties, decrease CBF but increase CPP CMRO2 ICP & IOP

question

Midazolam dose

answer

0.1-0.2 mg/kg

question

Midazolam onset

answer

30-60 sec

question

Midazolam peak

answer

3-5 min

question

Midzaolam duration

answer

15-80 min

question

Midazolam MOA

answer

GABA agonist- opening of Cl channels leading to hyper polarization

question

Dexmedetomidine dose

answer

1 mcg/kg over 10 min

question

Dexmedetomidine maintenance dose

answer

0.2-0.7 mcg/kg/min

question

Dexmedetomidine peak

answer

2-6 min

question

Dexmedetomidine duration

answer

0.5-2 hrs

question

Dexmedetomidine MOA

answer

presynaptic Alpha-2 agonist inhibiting Ca channels and activating K channels causing hyperpolarization and decreased release of catecholamine vesicles

question

Dexmedetomidine issues

answer

hypotension & bradycardia

question

Neosynephrine dose

answer

50-100 mcg

question

Neosynephrine onset

answer

<1 min

question

Neosynephrine peak

answer

<1 min

question

Neosynephrine duration

answer

15-20 min

question

Neosynephrine indication & MOA

answer

hypotention w/o bradycardia selective alpha-1 agonist causing vasoconstriction of arterioles and venuoles

question

Neosynephrine issues

answer

bradycardia

question

Ephedrine indication & MOA

answer

hypotension w/ bradycardia & bronchospasm Beta & Alpha agonist mix direct & indirect

question

Ephedrine dose

answer

5-20 mg

question

Ephedrine onset

answer

immediate

question

Ephedrine peak

answer

2-5 min

question

Ephedrine duration

answer

10-60 min

question

Ephedrine issues

answer

increased risk of arrhythmia

question

Epinephrine indication & MOA

answer

other vasopressors fail, total spinal, bronchospasm Alpha & Beta agonist, increased HR, bronchodilator

question

Epinephrine dose

answer

2-10 mcg

question

Epinephrine onset

answer

<1 min

question

Epinephrine peak

answer

<1 min

question

Epinephrine duration

answer

5-10 min

question

Esmolol indication & MOA

answer

Tachycardia, HTN Selective Beta-1 antagonist

question

Esmolol dose

answer

0.5-1 mg/kg

question

Esmolol onset

answer

1-2 min

question

Esmolol peak

answer

5 min

question

Esmolol duration

answer

10 min

question

Esmolol metabolism

answer

RBC esterases

question

Metoprolol indication & MOA

answer

HTN, SVT, Acute MI Selective Beta-1 antagonist

question

Metoprolol dose

answer

2-15 mg

question

Metoprolol onset

answer

<15 min

question

Metoprolol peak

answer

20 min

question

Metoprolol duration

answer

5-8 hrs

question

Metoprolol contraindications

answer

bradycardia & heart block

question

Labetalol indications & MOA

answer

HTN Alpha & Beta antagonist (1:7 - Alpha/Beta)

question

Labetalol dose

answer

2.5-20 mg

question

Labetalol onset

answer

2-5 min

question

Labetalol peak

answer

5-15 min

question

Labetalol duration

answer

2-4 hrs

question

Labetalol contraindications

answer

asthma, HF, bradycardia

question

Hydralazine indications & MOA

answer

HTN, SVR reduction in CHF patients activation of K channels causing hyperpolarization of smooth cells preventing vasoconstriction (requires Nitric Oxide for vasodilation)

question

Hydralazine dose

answer

0.1-0.2 mg/kg

question

Hydralazine onset

answer

5-20 min

question

Hydralazine peak

answer

10-80 min

question

Hydralazine duration

answer

2-4 hrs

question

Hydralazine S/E

answer

reflexive bradycardia (minimal with co-administration w/Beta Blocker)

question

A 23 yo F presents to your office for an evaluation of her third molars. Teeth #1 and #16 are erupted/malposed, and #17 and #32 are slightly mesioangular PBIs. On history you discover that she has asthma and smokes cigarettes, 1 PPD for the past 10 years. Her medications include Advair Inhaler BID, Proventil prn, and orthotrycycline BCP (although she occasionally misses a dose and she has not had her period for a couple months). On further questioning, you also find out that she takes a MVI, additional vit E, and an herbal "mood pack" containing St John's Wort, ecchinacea, ginko biloba, and garlic. She wants to be "asleep" during her surgery. What questions would you ask this patient, pertaining to the findings in the medical history?

answer

Aside from CC, HPI, PMedHx, PSurHx, FamHx, ALL, ROS... How frequent and severe are the asthma attacks, what precipitates them, has she ever been to the ER or hospitalized for them. Is she sexually active, and is there a possibility she could be pregnant?

question

What are your concerns and perioperative recommendations for any of the medications or supplements that this patient is taking?

answer

I am concerned that she is not very compliant with her BCPs. I am also concerned about the additional vitamin E and herbals, which can cause excessive bleeding. I would instruct her to stop those supplements 2 weeks prior to any surgical procedure. In addition, I would counsel her to use alternate forms of birth control for the remainder of her current menstrual cycle if antibiotics are prescribed during treatment, because they can render BCPs ineffective.

question

What is Advair?

answer

A combination B2 agonist/corticosteroid inhaled asthma medication used for prevention, not acute attacks. It contains salmeterol (slow acting B2 agonist) and fluticasone (corticosteroid), and comes in a diskus inhaler, that is activated by the patient's inhalation.

question

Describe your physical examination:

answer

I perform a head & neck exam, visualization/palpation/auscultation, cervical LAD, TMJ exam, intraoral exam looking for soft tissues lesions, infections, ulcerations, and evaluate the airway using the mallampati classification (I - entire pharynx visualized, II - most of uvula visualized, III - only soft palate visualized, IV - soft palate not visible) & physical factors like mandibular position/size and ability to extend neck. I look at pupils for size and reactivity, and assess CN V & VII function as pertinent to any potential surgical procedures. I auscultate the heart and lungs.

question

On auscultation, her lungs are clear and you hear a soft, but unmistakeably present systolic ejection murmur at the left sternal border. She has never been told that she has a murmur. How would you grade the heart murmur?

answer

Levine scale: 1. The murmur is only audible on listening carefully for some time. 2. The murmur is *faint* but immediately audible on placing the stethoscope on the chest. 3. A loud murmur readily audible but with no palpable thrill. 4. A loud murmur with a palpable thrill. 5. A loud murmur with a palpable thrill. The murmur is so loud that it is audible with only the rim of the stethoscope touching the chest. 6. A loud murmur with a palpable thrill. The murmur is audible with the stethoscope not touching the chest but lifted just off it.

question

Location refers to where the heart murmur is usually heard best. There are 4 places on the anterior chest wall to listen for heart murmurs; each of the locations roughly corresponds to a specific part of the heart and should be listened to (through the stethoscope) with the patient lying down, face up. The four locations are?

answer

Aortic region - the 2nd RIGHT intercostal space. Pulmonic region - the 2nd left intercostal spaces. Tricuspid region - the 5th left intercostal space (STERNAL) Mitral region - the 5th left mid-clavicular intercostal space. (near nipple)

question

What are possible etiologies for the murmur?

answer

Innocent or physiologic murmur, pregnancy, anemia, VSD, tricuspid or mitral valve dysfunction.

question

What actions would you take?

answer

Medical consultation to evaluate the murmur and need for bacterial endocarditis prophylaxis prior to dental/surgical procedures. I would order a urine pregnancy test immediately, and in my hospital setting, I would refer the patient to cardiology, who would evaluate her with auscultation using different maneuvers (left lateral decubitus brings out mitral murmurs and sitting forward accentuates aortic murmurs), likely an ECG, and possibly an echocardiogram to rule out valvular dysfunction.

question

What does inhalation do to accentuate the murmur?

answer

Inhalation leads to an increase in intrathoracic negative pressure, which increases the capacity of pulmonary circulation, thereby prolonging ejection time. This will affect the closure of the pulmonary valve. This finding, also called Carvallo's maneuver, has been found by studies to have a sensitivity of 100% and a specificity of 80% to 88% in detecting murmurs originating in the right heart. specifically positive Carvallo's sign describes the increase in intensity of a tricuspid regurgitation murmur with inspiration.

question

On referral to her physician, a pregnancy test is ordered and comes back positive. She is near the end of her first trimester. What is the likely etiology of the murmur?

answer

Physiologic murmur caused by the hyperdynamic state of pregnancy (increased cardiac output). These murmurs do not require SBE prophylaxis.

question

What will you advise her about the timing of her surgery?

answer

She should ideally wait until after delivery. Any procedures that must be performed, are most safely performed in the *2nd trimester* using local anesthesia, although severe infections and trauma must be managed at the time they present in most cases.

question

She develops a moderate to severe pericoronitis involving tooth #32 (with occlusal trauma from tooth #1) during her pregnancy. She has tender right submandibular nodes, localized erythema and swelling around tooth #32 with mild suppuration, and a temperature of 99.8 F. How would you manage this situation?

answer

I would extract tooth #1 with local anesthesia (lidocaine or mepivacaine, but not bupivacaine - it can cause CV collapse) and irrigate the #32 site with Chlorhexidine 0.12% oral rinse, and have the patient irrigate at home BID. I would prescribe PCN 500mg PO QID for 7 days, or Clindamycin 300mg PO QID for 7 days if she is PCN allergic. I would see her in 48 hours for a follow-up appointment.

question

What antibiotics are safe to use during pregnancy?

answer

PCN, cephalosporins, clindamycin

question

What local anesthetics are safe to use?

answer

Lidocaine and mepivacaine

question

What would be your anesthesia plan?

answer

Topical and local anesthesia. Fentanyl and Demerol are ok in small amounts during pregnancy, but benzodiazepines can cause birth defects (such as cleft lip & palate) early in the pregnancy.

question

You are taking out tooth #1 to alleviate a p-cor involving tooth #32. During the procedure the patient becomes light headed. Why is this occurring and what actions are you going to take?

answer

Likely compression of the Vena Cava, with decreased blood return to the heart. The treatment is to place the patient on her left side with her hip slightly elevated. I would also administer supplemental O2 by NC.

question

The patient recovers from the p-cor and goes on to an uncomplicated delivery. She presents 6 months later for removal of her remaining third molars. She no longer has a murmur on auscultation. She wants to be "completely asleep" for the surgery this time. What additional questions will you ask her?

answer

Is she breastfeeding? If she is, then she should pump and freeze breast milk to have available for several days after the surgery (until the anesthesia medications and any prescribed narcotic analgesics or antibiotics are out of the patient's system).

question

What is this patient's ASA classification?

answer

ASA 2 ASA 1-Normal healthy patient ASA 2-Controlled systemic disease without functional limitation ASA 3-Severe systemic disease with functional limitation ASA 4-Severe systemic disease that is a constant threat to life ASA 5-Moribund patient, not expected to survive without operation ASA 6-Brain-dead, organ donor (E)-Designator for any patient requiring an emergency operation

question

What are your preoperative instructions for this patient?

answer

Stop the vitamin E and herbals 2 weeks prior to surgery. NPO 6 hours prior, with small amounts of water allowed up to 2 hours prior to surgery. She must perform a urine HCG within 72 hrs prior to the surgery and she must have an adult escort with her to drive her home. She needs to bring her albuterol inhaler with her to the appointment, and continue to use her Advair BID throughout the perioperative period. She should ideally stop smoking several weeks prior to her surgery and refrain from smoking for at least a week postoperatively to minimize her risk of alveolar osteitis or impaired healing. I ask patients to remove any nail polish from their fingernails before the appointment and to wear comfortable, non-restrictive clothing.

question

Describe your anesthetic technique for an OPGA:

answer

I perform and supervise intubated general anesthetic cases in my hospital clinic, as a part of a residency training program. One surgeon performs the anesthesia and another performs the surgery. I have a nurse monitoring and recording vital signs during the procedure and recovery. After an immediate preoperative re-assessment, an 18-20ga peripheral IV is started, and a bag of LR is connected. Any indicated preoperative antibiotics are administered IVPB over 20-30 min. I pre-oxgenate for several minutes while placing monitors (pre-cordial stethoscope, pulse-ox, BP, and EKG leads). I give the patient midazolam for anxiolysis if indicated, but don't usually need it, and avoid it if possible to minimize recovery time. After obtaining the first set of vitals, I give 50 to 100 mcg of fentanyl over several minutes. Until recently, I used to give tubocurarine 3mg IVP, as a defasciculating dose at this point, telling the patient that they may have blurred vision and feel a subjective weakness or difficulty breathing. It has not been available recently. I induce general anesthesia with 2.5mg/kg Propofol IVP. I then make an attempt to mask ventilate the patient in order to assess the airway. If the airway is patent, then I administer Succinycholine 1.5mg/kg IVP, and wait approximately 1 min, until after muscle fasciculations subside. Decadron 8mg IVP is administered if indicated for the procedure. I then perform a direct laryngoscopy and administer approximately 50mg of lidocaine in the trachea with an LTA, to prevent stimulation of the airway with movement of the ETT. Without removing the laryngoscope, I pass an endotracheal tube, watching the cuff go past the cords. The stylet is removed, and the cuff inflated. I then hook up the anesthesia circuit to the ETT and verify position by auscultation, condensation in the ETT, ; ETCO2, and note the tube position at the teeth. The tube is secured and a throat pack placed. I place the patient on 60/40 nitrous oxide/O2 at a flow of about 4-5 l/min, and place them on the ventilator with a TV of approximately 8-10 ml/kg and a rate to keep the ETCO2 around 35. I administer a continuous propofol infusion, using a Baxter infusion pump, initially at 100mcg/kg/min. I administer local anesthetic, and perform the surgery. The propofol is gradually weaned down during the case, and the infusion stopped near the end of the procedure. The nitrous oxide is weaned and the patient placed on 100% O2 as the throat pack is removed. I allow the patient to emerge, through stage 2 (following commands and demonstrating good strength and respiratory pattern), prior to extubation. The patient is asked to open, inhale and hold it, and the bag squeezed to fill the lungs with air, just before dropping the cuff and gently pulling the endotracheal tube. The mask is placed and the patient monitored for adequate respirations prior to transport to the recovery room where the patient is constantly monitored until discharge.

question

The patient desires a general anesthetic and you decide to treat her in the Outpatient Surgery Center of your local hospital. The anesthetist induces anesthesia with Propofol, and is using Sevofluorane for maintenance. What are Propofol and Sevofluorane?

answer

Propofol is a substituted isopropylphenol IV sedative-hypnotic agent used for induction and maintenance of anesthesia. It is in a soybean fat emulsion with egg phosphatide, and is highly lipophilic, which increases it's ability to cross the blood-brain barrier. It produces a dose dependent CNS depression, has a fast onset and short duration, and is easily titrated, but can cause marked hypotension when administered in rapid bolus. The usual induction dose is 2-2.5mg/kg. Infusions of 25-200mcg/kg/min are useful for sedation or maintenance of general anesthesia. Sevofluorane is a fluorinated volatile anesthetic agent with a low blood/gas partition coefficient, therefore a rapid onset and recovery from anesthesia. The MAC is 1.71. It is useful in mask inductions for children, because it has less a less pungent odor and airway irritability than other volatile anesthetics. When used in combination, sevo and propofol may cause profound hypotension.

question

What is MAC, pertaining to volatile anesthetics?

answer

The concentration of an inhaled anesthetic, at 1ATM, that prevents skeletal muscle movement in response to a painful stimulus (skin incision) in 50% of patients. A MAC of 1.3 prevents movement in approximately 95% of individuals undergoing surgery. MAC can be used to compare potency of anesthetic gases.

question

During the case, the anesthetist complains of increasing airway pressures. What could be the cause?

answer

Circuit or ETT obstruction (kinking), airway secretions or mucous plugging, bronchospasm.

question

How should potential bronchospasm be treated intraoperatively, in this intubated patient?

answer

Suction ETT and trachea with suction catheter. Albuterol MDI 8-10 puffs into endotracheal tube on inspiration, through chamber, or a 60cc syringe connected to the anesthesia circuit close to the ETT. If this doesn't work, then epinephrine 0.3mg SC.

question

Near the end of the case, the anesthetist is now complaining that the ETCO2 is abnormally high, and non-responsive to increasing the ventilatory rate. The patient has also become mildly tachycardic. The CRNA asks you what you think is going on?

answer

Suspect Malignant Hyperthermia.

question

What is Malignant Hyperthermia?

answer

An inherited disease that manifests most often in children (1:12,000 pediatric anesthetics, 1:40,000 adult anesthetics). The gene for MH is also the genetic coding site for the calcium release channel of skeletal muscle sarcoplasmic reticulum. It is presumed that a defect in the calcium release channel permits sustained higher concentrations of calcium in the myoplasm and persistent muscle contraction when susceptible patients are exposed to triggering agents (depolarizing muscle relaxants and volatile anesthetics). The eventual result is an extreme hypermetabolic state, leading to respiratory and metabolic acidosis and death is not treated.

question

How do you recognize and treat Malignant Hyperthermia?

answer

Identifying individuals at risk, through a thorough history (and family history) of previous anesthetics is necessary. 70% of MH-susceptible patients have increases of resting concentrations of creatine kinase. The definitive diagnosis of susceptibility to MH requires skeletal muscle biopsy and in vitro isometric contracture testing in the presence of caffeine or halothane, or both. The earliest clinical signs of MH include unexplained sustained elevation in ETCO2, and tachycardia. Arterial hypoxemia, metabolic (due to lactic acidosis) and respiratory acidosis are followed by an eventual profound increase in body temperature (late finding). Treatment includes: initiating the emergency plan/activating EMS, stopping the triggering agent and changing the anesthesia circuit, hyperventilating with 100% O2, administering 2.5mg/kg Dantrolene Sodium IVP and repeat every 10-15 minutes as needed (up to 10mg/kg), initiate active cooling (cold IV saline, gastric lavage with cold saline, surface cooling), Sodium bicarbonate 1-2mEq/kg IV as guided by arterial pH, induce diuresis (hydration, mannitol, lasix), and monitor electrolytes (treat hyperkalemia with insulin and glucose). The patient must be transported to and managed in an ICU setting at the appropriate time.

Dosing of Propofol, Etomidate and Lidocaine

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