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ANESTHESIA PHARMACOLOGY : 

ANESTHESIA PHARMACOLOGY SFC HILL

OBJECTIVE : 

OBJECTIVE As a Special Forces Medic given a patient requiring anesthesia, administer anesthesia utilizing your knowledge of anesthesia pharmacology and applying the five rights (right patient, right drug, right amount, right route, right time) in accordance with JSOMTC student manual of anesthesia.

REASON : 

REASON As a Special Forces Medic the probability is high that you will be the only health care provider available to administer anesthesia.

PROCEDURES : 

PROCEDURES Review local/regional anesthesia pharmacology Review anesthesia pharmacology adjuncts Review intravenous anesthetics Review intravenous anesthetics reversal agent

Local/Regional Anesthetics : 

Local/Regional Anesthetics

Lidocaine : 

Lidocaine amide type anesthetic the most commonly used local anesthetic rapid onset and a duration of 60-75 minutes extended when solutions with epinephrine are used for up to 2 hours metabolized in the liver and excreted by the kidneys.

INDICATIONS Lidocaine : 

INDICATIONS Lidocaine used to produce local and regional anesthesia for surgical and diagnostic procedures

DOSE AND ROUTES Lidocaine : 

DOSE AND ROUTES Lidocaine Percutaneous infiltration: 0.5%, 1.0% Regional infiltration: 0.5% Peripheral nerve: 1.0%, 1.5%, 2.0% Max dose 4 mg/kg or 7 mg/kg with epinephrine Toxic IV dose: 250 mg

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Lidocaine : 

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Lidocaine contraindicated in patients with a known sensitivity to amide type anesthetics All local anesthetics can produce CNS stimulation, depression, or both

Chloroprocaine : 

Chloroprocaine ester type local anesthetic onset of action is rapid (6-12 min.) and duration of anesthesia is up to 60 min. rapidly metabolized in the plasma.

INDICATIONS Chloroprocaine : 

INDICATIONS Chloroprocaine production of local and regional anesthesia for surgical and diagnostic procedures

DOSE AND ROUTES Chloroprocaine : 

DOSE AND ROUTES Chloroprocaine Local infiltration: 2.0%, 3.0% for motor block Peripheral nerve block: 1.0%, 2.0% Maximum dose 11 mg/kg or 13 mg/kg with Epinephrine Toxic IV dose: 450 mg

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Chloroprocaine : 

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Chloroprocaine contraindicated in patients with known hypersensitivity to drugs of the PABA ester group All local anesthetics can produce CNS stimulation, depression, or both

Procaine : 

Procaine ester type local anesthetic slower onset of action than Lidocaine duration of action is approximately one hour primarily metabolized in the plasma

INDICATIONS Procaine : 

INDICATIONS Procaine used to produce local and regional anesthesia for surgical and diagnostic procedures

DOSE AND ROUTES Procaine : 

DOSE AND ROUTES Procaine Infiltration: 0.25%, 0.5% Nerve block: 1.0%, 2.0% Maximum dose 11 mg/kg or 13 mg/kg with Epinephrine Toxic IV dose: 450 mg

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Procaine : 

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Procaine Contraindicated in patients with a known hyper-sensitivity to PABA ester type anesthetics All local anesthetics can cause CNS stimulation, depression or both

Bupivicaine : 

Bupivicaine amide-type local anesthetic onset of action is slower than lidocaine and anesthesia is long acting metabolized in the liver and excreted by the kidneys normally provides 2-4 hours of anesthesia can be extended in some cases by using solution with epinephrine to 7 hours

INDICATIONS Bupivicaine : 

INDICATIONS Bupivicaine production of local or regional anesthesia for surgical, diagnostic, or obstetrical procedures.

DOSE AND ROUTES Bupivicaine : 

DOSE AND ROUTES Bupivicaine Local infiltration: 0.25% Peripheral nerve block: 0.25%, 0.5% Maximum dose 3 mg/kg or 4 mg/kg with Epinephrine Toxic IV dose 80 mg

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Bupivicaine : 

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Bupivicaine Contraindicated for use in pts with known hypersensitivity and in obstetrical paracervical blocks All local anesthetics can produce CNS stimulation, depression or both

Adjuncts to Anesthesia : 

Adjuncts to Anesthesia

Atropine : 

Atropine anticholinergic drug that blocks the muscarinic receptor sites (mainly organs innervated by the Vagus nerve) reduction in salivary and other airway secretions inhibits Acetylcholine at the parasympathetic neuroeffector junction, blocking vagal effects on the SA node; this enhances conduction through the AV node and speeds heart rate

Atropine : 

Atropine inhibits heat loss by suppressing perspiration antisialogogue effects last up to 4 hours increase in heart rate peaks in one hour.

INDICATIONS Atropine : 

INDICATIONS Atropine used preoperatively for diminishing secretions and blocking cardiac vagal reflexes

DOSE AND ROUTES Atropine : 

DOSE AND ROUTES Atropine 0.4-0.6 mg IM 45-60 prior to anesthesia

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Atropine : 

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Atropine may cause tachycardia excessive dryness of the mouth and throat dilation of the pupils fever, flushing of the face, confusion, mania, and hallucinations may increase intraocular pressure-contraindicating its use in narrow angle glaucoma

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Atropine : 

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Atropine contraindicated in obstructive uropathy, obstructive disease of the GI tract, myasthenia gravis, paralytic ileus, intestinal atony, unstable CV status in acute hemorrhage, and toxic megacolon crosses the blood brain barrier and may cause confusion, post-op somnolence and delirium, particularly in children and elderly

Promethazine : 

Promethazine antihistamine, antiemetic, and sedative activity, all of which are useful in preanesthetic medication weaker sedative than Diazepam best premedication for Ketamine competes (antagonist) for H1 receptor sites on effector cells prevents but does not reverse histamine-mediated responses

INDICATIONS Promethazine : 

INDICATIONS Promethazine is used for preoperative sedation and as an analgesic adjunct

DOSE AND ROUTES Promethazine : 

DOSE AND ROUTES Promethazine 25-50 mg Deep IM, IV, or PO 30 min prior to anesthesia If giving IV dilute with normal saline Never give SC as this is an irritating solution. Injections should be deep IM

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Promethazine : 

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Promethazine Contraindicated in pts. with increased intraocular pressure, intestinal obstruction, prostatic hypertrophy, bladder neck obstruction, epilepsy, bone marrow depression, coma, CNS depression, or stenosing peptic ulcers Additive effects with other Phenothiazines and CNS depressants

Intravenous Anesthetics : 

Intravenous Anesthetics

Review the Components of General Anesthesia : 

Review the Components of General Anesthesia Muscle Relaxation Unconsciousness Analgesia

Intravenous Anesthetics : 

Intravenous Anesthetics Muscle Relaxation

Diazepam : 

Diazepam Benzodiazepine with sedative and amnesic properties Depresses the CNS at the limbic and subcortical levels of the brain Depresses the ventilatory response to PaCO2

Diazepam : 

Diazepam Mild muscle relaxation mediated at the spinal cord level; not at the neuromuscular junction Highly alkaline pH No analgesic properties

INDICATIONS Diazepam : 

INDICATIONS Diazepam Basal sedation Induction agent Preanesthetic Drug Of Choice for seizures

DOSE AND ROUTES Diazepam : 

DOSE AND ROUTES Diazepam IV, IM, PO, and rectally Pre-op sedation: 5 to 10 mg PO 1h before surgery Induction of anesthesia: 0.1-0.2 mg/kg IV Seizures: 5-10 mg IV q5min up to 30 mg Basal sedation: Increments of 2.5 mg until pt. falls into light sleep (5-30 mg may be required)

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Diazepam : 

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Diazepam Apnea, respiratory depression, post-op respiratory depression contraindicated narrow angle glaucoma or patients < 6 m/o (in oral form) incompatible with many drugs; when given IV with other medications, the IV line should be adequately flushed should be injected < 5 mg/min to avoid respiratory arrest

Midazolam : 

Midazolam benzodiazepine that has a rapid onset with sedative and amnesic properties depresses the CNS at the limbic and subcortical levels of the brain depresses the ventilatory response to PaCO2

Midazolam : 

Midazolam no analgesic properties mild muscle relaxation mediated at the spinal cord; not at the neuromuscular junction water soluble--which allows for better absorption following IM injection

INDICATIONS Midazolam : 

INDICATIONS Midazolam pre-op sedative induction of anesthesia Conscious sedation commonly used for short diagnostic or endoscopic procedures

DOSE AND ROUTES Midazolam : 

DOSE AND ROUTES Midazolam may be given IM, PO, or IV Pre-op sedation: 0.07-0.08 mg/kg IM 1 hr prior Induction of anesthesia: 0.050 - 0.350 mg/kg IV Basal sedation: 0.035 mg/kg initially, then titrated slowly to a total dose of 0.1 mg/kg

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Midazolam : 

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Midazolam Apnea, respiratory depression, post-op respiratory depression Contraindicated in pts. with known hypersensitivity, and acute narrow angle glaucoma Tends to reduce BP and peripheral vascular resistance more than Diazepam

Reversal Agent : 

Reversal Agent For Benzodiazepine

Flumazenil : 

Flumazenil selective, competitive antagonist of benzodiazepines relatively short duration of action between one and two hours acts through competitive inhibition of GABA (benzodiazepine receptor in the CNS)

INDICATIONS Flumazenil : 

INDICATIONS Flumazenil Reversal of benzodiazepine sedation or overdose

DOSE AND ROUTES Flumazenil : 

DOSE AND ROUTES Flumazenil reversal of conscious sedation 0.2-1.0 mg IV q 20 min @ 0.2 mg/min overdose 1.0 mg IV @ 0.5 mg/min Maximum total safe total dose 3mg in an hour

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Flumazenil : 

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Flumazenil CNS excitation including seizures, nausea, dizziness, and agitation May precipitate acute withdrawal

Intravenous Anesthetics : 

Intravenous Anesthetics Analgesics

Morphine : 

Morphine most common opioid analgesic used in anesthesia both depressive and stimulatory effects binds with opiate receptor sites in the CNS, altering both perception of and emotional response to pain has little CV effect, but produces peripheral dilation

Morphine : 

Morphine blocks the responsiveness to elevation of PaCO2 tidal volume remaining unchanged and respiratory rate diminishes stimulates the chemoreceptor trigger zone in the medulla causing nausea and vomiting Hyperactive spinal reflexes, seen as truncal rigidity occasionally follow administration

Morphine : 

Morphine frequently causes constipation from decreased peristalsis can also cause Oddi's sphincter and bladder sphincter spasms, leading to biliary colic and urinary retention causes histamine release which can result in bronchial constriction and vasodilatation inactivated in the liver with 90% eliminated by the kidneys and 10% excreted in bile or found in feces

INDICATIONS Morphine : 

INDICATIONS Morphine used for the relief of moderate to severe pain

DOSE AND ROUTES Morphine : 

DOSE AND ROUTES Morphine May be given IM, SC or IV 1- 3 mg IV prn 10 -15 mg IM or SC q4h 2 - 20 mcg/kg/hr infusion rate

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Morphine : 

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Morphine Apnea, resp. depression Contraindicated in patients with asthma or acute bronchitis May have additive effects when combined with other CNS depressants Use with caution in pts with head injury, IICP, and seizures Orthostatic hypotension, N/V, urinary retention, bradycardia, CNS depression, and pupillary constriction

Nalbuphine : 

Nalbuphine synthetic opioid agonist-antogonist that binds with opiate receptor sites in the CNS, altering both perception of and emotional response to pain relative potency of Nalbuphine as compared to Morphine is 0.5 to 0.9 inactivated in the liver and eliminated primarily by secretion in the bile with fecal excretion

INDICATIONS Nalbuphine : 

INDICATIONS Nalbuphine relief of moderate to severe pain not a useful component in balanced anesthesia because of its ceiling analgesia action may be used as a pre-op sedative-analgesic

DOSE AND ROUTES Nalbuphine : 

DOSE AND ROUTES Nalbuphine There is a ceiling for analgesia that is not increased beyond doses greater than 0.4 mg/kg IV 10 mg q 3-6 hr prn SC, IV, IM

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Nalbuphine : 

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Nalbuphine adverse reactions of Nalbuphine are essentially the same as those of Morphine may cause respiratory depression with usual doses, however depression will not increase by larger doses (> 30 mg)

Reversal Agent : 

Reversal Agent For Narcotics

Naloxone : 

Naloxone narcotic antagonist use in the management and reversal of overdoses caused by narcotics or synthetic narcotics

INDICATIONS Naloxone : 

INDICATIONS Naloxone For the complete and partial reversal of depression caused by the following drugs: Narcotics: Morphine, Heroin, Dilaudid, Percodan, Methadone, Demerol, Paregoric, Codeine, and Fentanyl Synthetic Narcotics: Nubain, Stadol, Talwin, Darvon

DOSE AND ROUTES Naloxone : 

DOSE AND ROUTES Naloxone 1-2 MG IV q5min up to 3 times Continuos infusion may be started at 400 mcg/hr.

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Naloxone : 

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Naloxone Contraindicated in patients with known hypersensitivity May cause withdrawal type effects in abrupt reversals

Intravenous Anesthetics : 

Intravenous Anesthetics Unconsciousness

Ketamine : 

Ketamine nonbarbiturate, rapid acting general anesthetic dissociated from the environment, immobile, and unresponsive to pain profound analgesic

Ketamine : 

Ketamine selectively blocks the associative pathways producing sensory blockade Preserved pharyngeal-laryngeal reflexes normal or slightly enhanced skeletal muscle tone cardiovascular and respiratory stimulation

INDICATIONS Ketamine : 

INDICATIONS Ketamine sole agent for procedures that do not require skeletal muscle relaxation induction of anesthesia prior to the administration of other anesthetic agents supplementation of low potency agents

DOSE AND ROUTES Ketamine : 

DOSE AND ROUTES Ketamine may be injected IM or IV Induction: 1-2 mg/kg Slow IV Maintenance: 30-90 mcg/kg/min IV drip Intramuscular: 6.5-13 mg/kg IM 10 mg/kg IM will produce approximately 12-25 min of surgical plane.

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Ketamine : 

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Ketamine contraindicated in pts. with known hypersensitivity or can't tolerate a significant increase in blood pressure IV dose should be administered over 60 seconds. Rapid administration may cause respiratory depression or apnea

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Ketamine : 

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Ketamine BP, pulse rate, and respiratory rate are often stimulated Concomitant use of barbiturates or narcotics prolong recovery time

Are there any questions onIntravenousAnesthetics/Reversal Agents? : 

Are there any questions onIntravenousAnesthetics/Reversal Agents?

Are there any questions onAnesthesia Pharmacology? : 

Are there any questions onAnesthesia Pharmacology?

BREAK? : 

BREAK?

Propofol : 

Propofol Propofol is a diisopropylphenol intravenous hypnotic agent that produces rapid induction of anesthesia with minimal excitatory activity It undergoes extensive distribution and rapid elimination by the liver

INDICATIONS : 

INDICATIONS Conscious sedation Induction agent of anesthesia Maintenance of anesthesia Antiemetic

DOSE AND ROUTESConscious sedation : 

DOSE AND ROUTESConscious sedation 25 - 50 mg IV, Titrate slowly to desired effect (on set of slurred speech)

DOSE AND ROUTESInduction : 

DOSE AND ROUTESInduction 2 - 2.5 mg/kg IV, given slowly over 30 seconds in 2 - 3 divided doses

DOSE AND ROUTESMaintenance : 

DOSE AND ROUTESMaintenance 25 - 50 mg IV bolus Infusion 100 - 200 mcg/kg/min

DOSE AND ROUTESAntiemetic : 

DOSE AND ROUTESAntiemetic 10 mg IV

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS : 

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Reduce doses in elderly, hypovolemic, high risk surgical patients and with use of narcotics and sedative hypnotics Minimize pain by injecting into a large vein and/or mixing IV lidocaine (0.1 mg/kg) with the induction dose of Propofol

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS : 

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Not recommended for patient with increased intracranial pressure Should be administered with caution to patients with a history of epilepsy or seizures disorder

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS : 

ADVERSE REACTIONS, PRECAUTIONS, AND INTERACTIONS Soybean-fat emulsion vehicle of Propofol supports rapid growth of bacteria, and strict aseptic technique must be maintained during handling, Propofol ampule should be discarded after a single use Use is contraindicated in patients allergic to eggs or soybean oil

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