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

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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)
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)
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
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)
Metoprolol/Lopressor (dose)
(selective) 2.5 to 5mg q5 max dose 15mg
Metoprolol/Lopressor (duration)
(selective) 5-8 hours
Metoprolol/ Lopressor (onset)
Esmolol/ Brevibloc (onset)
(selective) 1-2 minutes
Esmolol/ Brevibloc (duration)
(selective) 5-10 minutes
Esmolol/ Brevibloc (bolus and infusion dose)
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)
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
Zofran (duration)
4-8 hours
Zofran (onset)
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)
Benadryl (duration)
3-6 hours
Dexamethasone (dose)
Dexamethasone (duration)
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)
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)
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)
Ephedrine (onset)
less than 1 minute
Ephedrine (duration)
10- 60 minutes
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
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
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
Ephedrine indication & MOA
hypotension w/ bradycardia & bronchospasm
Beta & Alpha agonist mix direct & indirect
Ephedrine dose
5-20 mg
Ephedrine onset
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
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)

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 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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