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 0.625-1.25 mg 30 minutes 2-4 hours Ephedrine 5-20 mg 2-5 minutes 10-60 minutes Metoclopramide 10 mg 60 minutes 1-2 hours Ondansetron 4 mg 30 minutes 3-4 hours Prochlorperazine 5-10 mg 15-30 minutes 3-4 hours Promethazine 25 mg 5 minutes 2 hours H2 Blockers: Cimetidine 300 mg 45-90 minutes 4-5 hours Famotidine 20 mg 30 minutes 10-12 hours Ranitidine 50 mg 30-60 minutes 5-8 hours Sodium Citrate (PO) 15-30 cc 1-3 minutes 2 hours 1
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 0.3-0.5 mg/kg 3-4 minutes 15 minutes-1 hour Midazolam 0.05-0.35 mg/kg 5-30 minutes 2-6 hours Dexmedetomidine 0.5-1 ug/kg 10 minutes 4 hours Etomidate 0.1-0.4 mg/kg 1 minute 3-10 minutes Inhalation: Nitrous oxide 5 minutes Sevoflurane 5-10 minutes Ketamine 1-2.5 mg/kg 1 minute 5-15 minutes Methohexital 1.5-2.5 mg/kg 45 seconds 5-10 minutes Narcotics: Alfentanyl 50-150 ug/kg 1-2 minutes 10-15 minutes Fentanyl 5-30 ug/kg 5-15 minutes 30-60 minutes Remifentanil 0.5-1 ug/kg 90 seconds 5-10 minutes Sufentanyl 2-10 ug/kg 3-5 minutes 20-45 minutes Propofol 1.5-2.5 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
ANALGESICS Narcotic: Remifentanil 0.5-1 ug/kg 90 seconds 5-10 minutes Alfentanyl 10-25 ug/kg 1-2 minutes 10-15 minutes Sufentanyl 0.2-0.6 ug/kg 3-5 minutes 20-45 minutes Fentanyl 1-2 ug/kg 5-15 minutes 30-60 minutes Meperidine 0.5-2 mg/kg 5-20 minutes 2-4 hours Morphine 0.1-0.2 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 30-60 mg 1-3 hours 3-7 hours ANALGESICS Fentanyl Meperidine Methadone Morphine respiratory/circulatory depression, bradycardia, nausea/vomiting, 75-125 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 0.7-1 mg/kg 60 seconds 4-6 minutes Non-Depolarizing: Cistracurium 0.15-0.2 mg/kg 3-5 minutes 20-35 minutes Rocuronium 0.6-1.2 mg/kg 1-2 minutes 10-20 minutes Vecuronium 0.08-0.1 mg/kg 3-5 minutes 25-30 minutes Pancuronium 0.04-0.1 mg/kg 3-5 minutes 40-65 minutes 3
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 0.5-1.0 mg/kg 1-5 minutes 5-20 minutes Neostigmine 0.05 mg/kg 3-14 minutes 40-60 minutes Pyridostigmine 0.1-0.25 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
ANTIARRHYTHMICS Adenosine 6-12 mg 20-30 seconds 3-7 seconds Amiodarone 150-300 mg 10 minutes 30-45 minutes Amiodarone 0.5 mg/min 10 minutes Infusion Digoxin 0.5-1.0 mg 1-4 hours 3-4 days Diltiazem 10-20 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 30-60 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 10-20 min Labetolol 2.5-20 mg 5-15 minutes 2-4 hours Metoprolol 5-15 mg 20 minutes 5-8 hours Propranolol 0.5-3.0 mg 1 minute 1-6 hours Enalapril 1.25 mg 15 minutes 6 hours Fenoldopam 0.05-0.25ug/kg/m 20 minutes Infusion Hydralazine 2.5-40 mg 10-60 minutes 2-4 hours Nicardipine 5-15 mg/hr 10 minutes 2-6 hours Nitroglycerin 50-100 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
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 0.4-1 mg 2 minutes 1-2 hours Glycopyrrolate 0.1-0.2 5 minutes 2-3 hours Calcium Chloride 5-10 mg/kg 10-30 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 10-60 minutes Epinephrine 10 ug 1 minute 5-10 minutes Epinephrine 1-4 ug/min 1 minute Infusion Milrinone 0.5 ug/kg loading Milrinone 0.375-.75 ug/kg/m5 minutes Infusion Norepinephrine 2-4 ug/min 1 minute Infusion Phenylephrine 50-100 ug 1 minute 15-20 minutes Phenylephrine 40-60 ug/min 1 minute Infusion Vasopressin 40 units 1 minute 30-60 minutes Vasopressin 0.2-0.4 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
LOCAL ANESTHETICS Bupivacaine less than 150 mg 2-10 minutes 3-6 hours Lidocaine 1 mg/kg 1-2 minutes 10-20 minutes Ropivacaine less than 200 mg 10-20 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 0.2-1 mg 2-10 minutes 45-90 minutes Naloxone 0.1-2 mg 5-15 minutes 1-4 hours Physostigmine 0.5-2 mg 5-10 minutes 30 minutes-5 hours 7
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