ANESTHESIA DRUG REVIEW

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1 ANESTHESIA REVIEW CAPA S 39 TH ANNUAL CONFERENCE PALM SPRINGS OCTOBER 10, 2015 ROBERT F. KOPEL, MD, FACP, FCCP HOAG HOSPITAL CARDIAC ANESTHESIOLOGIST ASSISTANT CLINICAL PROFESSOR UCLA SCHOOL OF MEDICINE TYPES OF ANESTHESIA Pre medication Monitored Anesthesia Care (MAC) Regional Epidural - Single or Continuous Spinal - Single of Continuous Upper and Lower Extremity Blocks Brachial plexus Femoral Sciatic Transverse abdominis plane General Induction, Maintenance, Emergence Amnesia Analgesia Hypnotic Muscle relaxation ANTINAUSEANTS AND ANTIEMETICS Droperidol mg 30 minutes 2-4 hours Ephedrine 5-20 mg 2-5 minutes minutes Metoclopramide 10 mg 60 minutes 1-2 hours Ondansetron 4 mg 30 minutes 3-4 hours Prochlorperazine 5-10 mg minutes 3-4 hours Promethazine 25 mg 5 minutes 2 hours H2 Blockers: Cimetidine 300 mg minutes 4-5 hours Famotidine 20 mg 30 minutes hours Ranitidine 50 mg minutes 5-8 hours Sodium Citrate (PO) cc 1-3 minutes 2 hours 1

2 ANTINAUSEANTS AND ANTIEMETICS Droperidol Ephedrine hypotension, tachycardia, drowsiness, hyperactivity, severe restlessness, extrapyramidal reaction, increased QT interval antiemetic effect Metoclopramide circulatory depression/stimulation, extrapyramidal reaction, drowsiness, increased gastric emptying, antiemetic, reflux treatment, do not use with a patient on MAO inhibitors Ondansetron extrapyramidal reaction Prochlorperazine circulatory depression/stimulation, extrapyramidal reaction Promethazine Cimetidine Famotidime Ranitidine drowsiness, dizziness, tinnitus, double vision bradycardia, somnolence, confusion, disorientation INDUCTION S Benzodiazepines: Diazepam mg/kg 3-4 minutes 15 minutes-1 hour Midazolam mg/kg 5-30 minutes 2-6 hours Dexmedetomidine ug/kg 10 minutes 4 hours Etomidate mg/kg 1 minute 3-10 minutes Inhalation: Nitrous oxide 5 minutes Sevoflurane 5-10 minutes Ketamine mg/kg 1 minute 5-15 minutes Methohexital mg/kg 45 seconds 5-10 minutes Narcotics: Alfentanyl ug/kg 1-2 minutes minutes Fentanyl 5-30 ug/kg 5-15 minutes minutes Remifentanil ug/kg 90 seconds 5-10 minutes Sufentanyl 2-10 ug/kg 3-5 minutes minutes Propofol mg/kg 1 minute 5-10 minutes Sodium Thiopental 3-5 mg/kg 30 seconds 5-15 minutes INDUCTION S Midazolam Dexmedetomidine Etomidate Nitrous oxide Sevoflurane Ketamine Alfentanyl Fentanyl Remifentanil Sufentanyl Propofol respiratory/circulatory depression, prolonged emergence, agitation, antagonized by flumazenil hypotension, hypertension, nausea, bradycardia, tachycardia adrenal suppression respiratory/circulatory depression, nausea/vomiting respiratory/circulatory depression, hypertension, tachycardia, emergence delirium, hypersalivation respiratory/circulatory depression, bradycardia, nausea/vomiting respiratory/circulatory depression, hiccups, no analgesia, antiemetic effect, do not use with allergy to eggs Sodium Thiopental respiratory/circulatory depression, nausea/vomiting, emergence delirium, antianalgesic effect 2

3 ANALGESICS Narcotic: Remifentanil ug/kg 90 seconds 5-10 minutes Alfentanyl ug/kg 1-2 minutes minutes Sufentanyl ug/kg 3-5 minutes minutes Fentanyl 1-2 ug/kg 5-15 minutes minutes Meperidine mg/kg 5-20 minutes 2-4 hours Morphine mg/kg 5-20 minutes 2-7 hours Hydromorphone 0.02 mg/kg 5-20 minutes 2-4 hours Methadone 0.1 mg/kg 3-5 minutes 4-6 hours Nalbuphine 5-10 mg 5-15 minutes 3-6 hours Non-Narcotic: Acetaminophen 1000 mg 5-10 minutes 6 hours Ketorolac mg 1-3 hours 3-7 hours ANALGESICS Fentanyl Meperidine Methadone Morphine respiratory/circulatory depression, bradycardia, nausea/vomiting, times more potent than morphine respiratory/circulatory depression, nausea/vomiting, seizures in high doses, do not use with a patient on MAO inhibitors, 1/10 the potency of morphine only NMDA receptor antagonist respiratory/circulatory depression, nausea/vomiting, urinary retention, narcotics are antagonized by naloxone Hydromorphone similar side effects to morphine, 5-7 times more potent than morphine Acetaminophen Ketorolac nausea, vomiting, headache no depressed ventilation, prolonged bleeding time, analgesic potency of 30 mg equals 9 mg of morphine NEUROMUSCULAR BLOCKERS Depolarizing: Succinylcholine mg/kg 60 seconds 4-6 minutes Non-Depolarizing: Cistracurium mg/kg 3-5 minutes minutes Rocuronium mg/kg 1-2 minutes minutes Vecuronium mg/kg 3-5 minutes minutes Pancuronium mg/kg 3-5 minutes minutes 3

4 NEUROMUSCULAR BLOCKERS Succinylcholine very short acting, increased: intracranial pressure, intraocular pressure, intragastric pressure, potassium, profound bradycardia in children, treat with an anticholinergic first, malignant hyperthermia, pseudocholinesterase deficiency Cisatracurium Pancuronium Rocuronium Vecuronium hypotension, inadequate block, prolonged block NEUROMUSCULAR BLOCKER REVERSAL Edrophonium mg/kg 1-5 minutes 5-20 minutes Neostigmine 0.05 mg/kg 3-14 minutes minutes Pyridostigmine mg/kg 15 minutes 90 minutes NEUROMUSCULAR BLOCKER REVERSAL Edrophonium Neostigmine Pyridostigmine bradycardia, tachycardia, AV block, nodal rhythm, bronchospasm, nausea/vomiting, increased oral secretions 4

5 ANTIARRHYTHMICS Adenosine 6-12 mg seconds 3-7 seconds Amiodarone mg 10 minutes minutes Amiodarone 0.5 mg/min 10 minutes Infusion Digoxin mg 1-4 hours 3-4 days Diltiazem mg 1 minute 2-5 hours Lidocaine 1 mg/kg 1-2 minutes 5-20 minutes Procainamide 1 gram 5-15 minutes 3 hours Magnesium Sulfate 1-2 grams 1-2 minutes Variable Verapamil 5-10 mg 10 minutes minutes ANTIARRHYTHMICS Adenosine Amiodarone Digoxin Diltiazem Lidocaine Procainamide flushing, dyspnea, chest pain, bradycardia conduction delay, liver, lung, thyroid toxicity atrial and ventricular arrhythmia, anorexia, nausea, vomiting, diarrhea, visual disturbances, mental status changes hypotension, conduction delay respiratory/circulatory depression, seizure hypotension, negative inotrope, prolonged QT interval, conduction delay Magnesium Sulfate flushing, sweating, bradycardia, hypotension Verapamil hypotension, conduction delay HYPERTENSION Beta Blocker: Atenolol 5-10 mg 5 minutes 12 hours Esmolol 5-10 mg 5 minutes min Labetolol mg 5-15 minutes 2-4 hours Metoprolol 5-15 mg 20 minutes 5-8 hours Propranolol mg 1 minute 1-6 hours Enalapril 1.25 mg 15 minutes 6 hours Fenoldopam ug/kg/m 20 minutes Infusion Hydralazine mg minutes 2-4 hours Nicardipine 5-15 mg/hr 10 minutes 2-6 hours Nitroglycerin ug 1-5 minutes 3-5 minutes Nitroglycerin 5-50 ug/min 1-5 minutes 3-5 minutes Nitroprusside Titrate 1-2 minutes Infusion 5

6 HYPERTENSION Atenolol Esmolol Labetolol Metoprolol Propranolol Enalapril Fenoldopam Hydralazine Nicardipine Nitroglycerin Nitroprusside hypotension, bradycardia, AV block, bronchospasm confusion, nausea/vomiting hypotension, anaphylactoid reaction, pulmonary edema, arrhythmia, angina hypotension tachycardia, palpitations, angina hypotension, tachycardia, nausea/vomiting, headache tachycardia, palpitations, hypotension tachycardia, palpitations, hypotension, cyanide toxicity HYPOTENSION Anticholinergics: Atropine mg 2 minutes 1-2 hours Glycopyrrolate minutes 2-3 hours Calcium Chloride 5-10 mg/kg seconds Variable Dobutamine 2-20 ug/kg/min 2 minutes Infusion Dopamine 2-20 ug/kg/min 5 minutes Infusion Ephedrine 5-20 mg 2-5 minutes minutes Epinephrine 10 ug 1 minute 5-10 minutes Epinephrine 1-4 ug/min 1 minute Infusion Milrinone 0.5 ug/kg loading Milrinone ug/kg/m5 minutes Infusion Norepinephrine 2-4 ug/min 1 minute Infusion Phenylephrine ug 1 minute minutes Phenylephrine ug/min 1 minute Infusion Vasopressin 40 units 1 minute minutes Vasopressin units/min 1 minute Infusion HYPOTENSION Atropine Calcium Chloride Dobutamine Dopamine Ephedrine Epinephrine Glycopyrrolate Milrinone Norepinephrine Phenylephrine Vasopressin tachycardia, bradycardia, confusion, hallucinations, nervousness, urinary retention, blurred vision, mydriasis, crosses the blood-brain barrier bradycardia, arrhythmia hypertension, arrhythmia, ischemia, increased rate with atrial fibrillation hypertension, arrhythmia, ischemia hypertension, tachycardia, arrythmias hypertension, tachycardia, arrhythmias, angina vagolytic, tachycardia, confusion, urinary retention, antisialagogue, does not cross the blood-brain barrier ventricular arrhythmia hypertension, tachycardia, arrhythmia, angina, tissue hypoxia hypertension, bradycardia, arrhythmias cardiac arrest, myocardial infarction, pulmonary edema, cerebral hemorrhage, bowel ischemia 6

7 LOCAL ANESTHETICS Bupivacaine less than 150 mg 2-10 minutes 3-6 hours Lidocaine 1 mg/kg 1-2 minutes minutes Ropivacaine less than 200 mg minutes 3-6 hours LOCAL ANESTHETICS Bupivacaine intractable cardiac arrest, treat with intralipid Lidocaine Ropivacaine respiratory/circulatory depression, seizure MISCELLANEOUS Diphenhydramine25-50 mg 1-3 hours 3-7 hours Flumazenil mg 2-10 minutes minutes Naloxone mg 5-15 minutes 1-4 hours Physostigmine mg 5-10 minutes 30 minutes-5 hours 7

8 MISCELLANEOUS Diphenhydramine Flumazenil Naloxone Physostigmine hypotension, palpitations, seizures, sedation, confusion, urinary retention tachycardia, bradycardia, arrhythmias, hypertension, angina, seizures, agitation tachycardia, hypertension, hypotension, arrhythmias, seizures, pulmonary edema bradycardia, bronchospasm, seizures, salivation 8

Intravenous Infusions

Intravenous Infusions 1) An IV insulin infusion can be used for patients: a) with out of control diabetes b) with DKA (Diabetic Ketoacidosis) c) after a heart attack 2) Hyperglycemia is an adaptive response