USC Nurse Anesthesia Clinical Pharmacology Test Dose, Onset, Duration, Anesthesia Pharmacology

Propofol (induction dose)
1-2.5 mg/kg

Propofol (maintenance)
100-200 mcg/kg/min

Propofol (conscious sedation)
25-75 mcg/kg/min

Propofol (onset)
30 seconds

Propofol (duration)
3-8 minutes

Etomidate (induction dose)
0.2-0.6 mg/kg

Etomidate (onset)
30-60 seconds

Etomidate (duration)
3-5 minutes

Lidocaine (induction dose)
1.5 mg/kg

Lidocaine (max LA dose w/out Epi)
4 mg/kg

Lidocaine (max LA dose w/ Epi)
7 mg/kg

Ketamine (IV dose induction)
2-4 mg/kg

Ketamine (PO)
10mg/kg

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

Ketamine (IM dose)
4-6 mg/kg

Ketamine (IV onset)
1-2 minutes

Ketamine (IM onset)
3-8 minutes

Ketamine (IV duration)
6-15 minutes

Ketamine (IM duration)
15-20 minutes

Ketamine (conscious sedation)
0.25-0.5 mg/kg IV

Succinylcholine (IV onset)
30-60 seconds

Succinylcholine (IM onset)
2-3 minutes

Succinylcholine (IV duration)
3-5 minutes

Succinylcholine (IM duration)
10-30 minutes

Succinylcholine (IV induction)
1-1.5 mg/kg

Succinylcholine (IM dose)
3 mg/kg

Succinylcholine (laryngospasm dose)
20 mg IV

Vecuronium (IV induction)
0.1 mg/kg

Vecuronium (Maintenance gtt)
1 mcg/kg/min

Vecuronium (onset)
2-4 minutes

Vecuronium (duration)
30-60 minutes

Cisatracurium (duration)
30-60 minutes

Cisatracurium (onset)
2-4 minutes

Cisastracurium (IV induction)
0.1 mg/kg

Cisastracurium (maintenance)
1-3 mcg/kg/min

Rocuronium (induction dose)
0.6-1.2 mg/kg

Rocuronium (maintenance)
5-12 mcg/kg/min

Rocuronium (duration)
30-60 minutes

Rocuronium (onset)
60-90 seconds

Atracurium (induction)
0.5 mg/kg

Atracurium (duration)
30-60 minutes

Atracurium (maintenance)
3-5 mcg/kg/min

Atracurium (onset)
2-4 minutes

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

Ofirmev (onset/peak/duration)
10 minutes/ 1hr/ 4-6 hours

Hydrocortisone (dose)
250mg IV

Scopolamine (IV/IM dose)
0.3- 0.6 IV/IM

Scopolamine Patch (dose/onset/ duration)
1.5mg total dosage for patch; 4 hours/ 3 days

Scopolamine (onset IV)
8-10 minutes

Scopolamine (onset IM)
30 minutes

Scopolamine (duration IV)
2 hours

Scopolamine (duration IM)
4 hours

Dopamine (onset)
5 minutes

Dopamine (duration)
minutes after discontinuing

Dopamine (dosing)
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)

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

Phenylephrine (duration)
10-15 minutes

Phenylephrine (onset)
immediate

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

Precedex (loading dose)
1 mcg/kg IV over 10 minutes

Precedex (Maintenance Drip)
0.2-1.4 mcg/kg/hr

Precedex (fiberoptic intubation)
0.7 mcg/kg/hr

Precedex (procedural sedation)
start 0.6 mcg/kg/hr and titrate

Precedex (duration)
10-30 min after infusion stops

Precedex (onset)
10-20 minutes

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

Nitroglycerine (duration)
3-5 minutes

Nitroglycerine (onset)
1 minute

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

Hydralazine (duration)
4-8 hours

Hydralazine (onset)
15-20 minutes

Labetalol/ Trandate (non-selective) IV intermittent dose
0.25mg/kg

Labetalol/ Trandate (non-selective) Infusion dose
up to 2 mg/min

Labetalol/ Trandate (non-selective) IV bolus dose
20mg-80mg q10 (start with 20 and work up 300mg max)

Labetalol (duration)
2-4 hours

Labetalol/Trandate (onset)
immediately

Metoprolol/Lopressor (dose)
(selective) 2.5 to 5mg q5 max dose 15mg

Metoprolol/Lopressor (duration)
(selective) 5-8 hours

Metoprolol/ Lopressor (onset)
immediately

Esmolol/ Brevibloc (onset)
(selective) 1-2 minutes

Esmolol/ Brevibloc (duration)
(selective) 5-10 minutes

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

Propanolol/ Inderal (dose)
(non selective) IV 1mg q5 minutes up to 5mg

Propanolol/Inderal (onset)
(non selective) 15 minutes

Propanolol/Inderal (duration)
6 hours

Epinephrine (onset)
less than a minute

Epinephrine (duration)
5-10 minutes

Epinephrine (peak)
1-2 minutes

Epinephrine (iv push)
10-100mcg

Epinephrine (Infusion)
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

Norepinephrine (infusion dose)
0.01-0.2 mcg/kg/min

Norepinephrine (onset)
less than 1 minute

Norepinephrine (duration)
2-10 minutes

Norepinephrine (peak)
1-2 minutes

Albuterol/ Proventil/ Ventolin (dose)
90 mcg/inhalation 2 puff MDI q4-6 hours
2.5mg neb q4-6 hours

Albuterol/ Proventil/ Ventolin (duration)
6-12 hours

Albuterol/ Proventil/ Ventolin (onset)
15-30 minutes

Zofran (dose)
4-8mg IV
(0.15mg/kg)

Zofran (duration)
4-8 hours

Zofran (onset)
rapid

Granisetron (Kytril; IV and PO dose)
1 mg IV
2 mg PO

Promethazine (dose)
12.5-25 mg IV
6.25mg/5ml PO

Promethazine (duration)
4-12 hours

Promethazine (onset)
3-5 minutes

Metoclopramide (dose)
10-20mg IV

Metoclopramide (duration)
1-2 hours

Metoclopramide (onset)
1-3 minutes

Ranitidine (dose)
50-100 mg IV
(1-2.5 mg/kg)

150-300 PO

Flumazenil (dose)
0.2 mg/kg (slow titration max 3mg)

Flumazenil (onset)
1-2 minutes

Flumazenil (duration)
45-90 minutes

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

Benadryl (duration)
3-6 hours

Dexamethasone (dose)
5-10mg

Dexamethasone (duration)
variable

Dexamethasone (onset)
1 hour

Naloxone (dose)
40-100 mcg

Naloxone (duration)
20-60 minutes

Naloxone (onset)
2 minutes

Ketoralac (dose)
30 or 60mg

Ketoralac (duration)
4-6 hours

Ketoralac (onset)
30 minutes

Indigo Carmine
(40mg/5ml vial) 5mg

Furosemide (dose)
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)

Lasix (duration)
2 hours IV
6-8 hours PO

Lasix (onset)
5 min IV
30 min IM
30-60 min PO/SL

Lasix (peak)
<15min IV 1-2 hours PO/SL

Oxytocin (dose)
0.5-8 mU/min

Hemabate/ Carboprost tromethamine (dose)
250mcg IM initial
repeat PRN q 1.5-3.5 hours

Methergine/ Methylergonovine (dose)
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)

Sublimaze/Fentanyl (IV dose)
25-100mcg

Sublimaze/Fentanyl (IV duration)
0.5-1 hour

Fentanyl (peak)
20-30 minutes

Sublimaze/Fentanyl (IV onset)
2-5 minutes

Hydromorphone (IV onset)
15-30 minutes

Hydromorphone (IV duration)
4-5 hours

Hydromorphone (IV dose)
0.25 mg -1mg

Hydromorphone (peak)
30-90 minutes

Morphine (IV dose)
2-10mg

Morphine (IV duration)
4-5 hours

Morphine (IV onset)
20 minutes

Morphine (IV peak)
30-60 minutes

Sufentanil (IV dose)
0.5 mcg/kg

Sufentanil (IV onset)
1-3 minutes

Sufentanil (IV duration)
dose dependent

Remifentanil (IV induction and infusion dose)
0.5-1 mcg/kg (induction)
0.05-2 mcg/kg/min (infusion)

Remifentanil (IV onset)
1 minute

Remifentanil (IV duration)
5-10 minute

Remifentanil (peak)
1 minute

Midazolam (onset)
IV 1-2 minutes
IM 15 minutes
PO 30 minutes

Midazolam (duration)
IV 20-50 minutes
IM up to 6 hours

Midazolam (IM, IV, Induction dose)
IM 0.07 mg/kg
IV 0.02-0.03 mg/kg
Induction 0.1-0.2 mg/kg

Edrophonium (dose)
0.05-0.1 mg/kg

Edrophonium (duration)
30-60 minutes

Edrophonium (onset)
5-10 minutes

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

Atropine (duration)
2-6 hours

Atropine (onset)
30-60 seconds

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

Neostigmine (duration)
45-90 minutes

Neostigmine (onset)
5-15 minutes

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

Glycopyrrolate (onset)
1-3 minutes

Glycopyrrolate (duration)
Vagal effects about 2 hours, decreased salivation for 7 hours

Vasopressin (dose)
Bolus 10-20 units
0.04-0.1 unit/min

Vasopressin (duration)
10-30 minutes

Vasopressin (onset)
1-5 minutes

Vasopressin (peak)
5 minutes

Ephedrine (dose)
5-10mg

Ephedrine (onset)
less than 1 minute

Ephedrine (duration)
10- 60 minutes

Atracurium
0.5 mg/kg

Succinylcholine induction dose
0.5-1 mg/kg
RSI: 1-1.5 mg/kg

Succinylcholine onset
30 sec

Succinylcholine duration
4-6 min

Succinylcholine MOA
Succinylcholine MOA
binds to nicotinic ACh receptors at the NMJ causing depolarization

Rocuronium induction dose
o.6-1.2 mg/kg

Rocuronium onset
45-90 sec

Rocuronium duration
15-150 min

Non-depolarizing NMBA MOA
competitive binding of nicotinic ACh receptors at the NMJ, preventing depolarization

Cisatracurium induction dose
0.2 mg/kg

Cisatracurium onset
90-120

Cisatracurium duration
20-40 min

Fentanyl dose
50-150 mcg

Fentanyl onset
within 30 sec

Fentanyl peak
3-5 min (6.8 min)

Fentanyl duration
30-60 min

Fentanyl MOA
Mu 1&2 agonist

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

Remifentanil dose
0.05-2 mcg/kg/min

Remifentanil onset
within 30 sec

Remifentanil peak
3-5 min

Remifentanil duration
5-10 min

Remifentanil metabolism
plasma cholinesterases

Dilaudid dose
0.5-2 mg

Dilaudid onset
almost immediate

Dilaudid peak
5-20 min

Dilaudid duration
2-4 hrs

Dilaudid issues
muscle rigidity

Morphine dose
1-15 mg

Morphine onset
<1 min

Morphine peak
5-20 min

Morphine duration
2-7 hrs

Morphine issues
avoid in asthma and hypotension because of histamine release

Propofol dose
1-2 mg/kg

Propofol maintenance dose
50-150 mcg/kg/min

Propofol onset
30 sec

Propofol peak
1 min

Propofol duration
5-10 min

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

Propofol properties & issues
anti-emetic
hypotension, irritation on injection

Ketamine dose
0.5-1 mg/kg

Ketamine onset
<30 sec

Ketamine peak
1 min

Ketamine duration
5-15 min

Ketamine MOA
inhibits glutamate @ the NMDA receptor

Ketamine metabolism
cytochrome P450 system

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

Midazolam dose
0.1-0.2 mg/kg

Midazolam onset
30-60 sec

Midazolam peak
3-5 min

Midzaolam duration
15-80 min

Midazolam MOA
GABA agonist- opening of Cl channels leading to hyper polarization

Dexmedetomidine dose
1 mcg/kg over 10 min

Dexmedetomidine maintenance dose
0.2-0.7 mcg/kg/min

Dexmedetomidine peak
2-6 min

Dexmedetomidine duration
0.5-2 hrs

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

Dexmedetomidine issues
hypotension & bradycardia

Neosynephrine dose
50-100 mcg

Neosynephrine onset
<1 min

Neosynephrine peak
<1 min

Neosynephrine duration
15-20 min

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

Neosynephrine issues
bradycardia

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

Ephedrine dose
5-20 mg

Ephedrine onset
immediate

Ephedrine peak
2-5 min

Ephedrine duration
10-60 min

Ephedrine issues
increased risk of arrhythmia

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

Epinephrine dose
2-10 mcg

Epinephrine onset
<1 min

Epinephrine peak
<1 min

Epinephrine duration
5-10 min

Esmolol indication & MOA
Tachycardia, HTN
Selective Beta-1 antagonist

Esmolol dose
0.5-1 mg/kg

Esmolol onset
1-2 min

Esmolol peak
5 min

Esmolol duration
10 min

Esmolol metabolism
RBC esterases

Metoprolol indication & MOA
HTN, SVT, Acute MI
Selective Beta-1 antagonist

Metoprolol dose
2-15 mg

Metoprolol onset
<15 min

Metoprolol peak
20 min

Metoprolol duration
5-8 hrs

Metoprolol contraindications
bradycardia & heart block

Labetalol indications & MOA
HTN
Alpha & Beta antagonist (1:7 – Alpha/Beta)

Labetalol dose
2.5-20 mg

Labetalol onset
2-5 min

Labetalol peak
5-15 min

Labetalol duration
2-4 hrs

Labetalol contraindications
asthma, HF, bradycardia

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

Hydralazine dose
0.1-0.2 mg/kg

Hydralazine onset
5-20 min

Hydralazine peak
10-80 min

Hydralazine duration
2-4 hrs

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

Meto

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?

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?

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

What is Advair?
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.

Describe your physical examination:
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.

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?

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.

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?
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)

What are possible etiologies for the murmur?
Innocent or physiologic murmur, pregnancy, anemia, VSD, tricuspid or mitral valve dysfunction.

What actions would you take?
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.

What does inhalation do to accentuate the murmur?
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.

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?

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

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

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?
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.

What antibiotics are safe to use during pregnancy?
PCN, cephalosporins, clindamycin

What local anesthetics are safe to use?
Lidocaine and mepivacaine

What would be your anesthesia plan?
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.

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?
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.

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?

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).

What is this patient’s ASA classification?
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

What are your preoperative instructions for this patient?
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.

What are the ASA Fasting guidelines for anesthesia?
What are the ASA Fasting guidelines for anesthesia?

Describe your anesthetic technique for an OPGA:
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.

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?

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.

What is MAC, pertaining to volatile anesthetics?
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.

During the case, the anesthetist complains of increasing airway pressures. What could be the cause?
Circuit or ETT obstruction (kinking), airway secretions or mucous plugging, bronchospasm.

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

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?
Suspect Malignant Hyperthermia.

What is Malignant Hyperthermia?
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.

How do you recognize and treat Malignant Hyperthermia?
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.

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