MH, PONV, temp control Flashcards

1
Q

Postoperative Nausea and Vomiting (PONV)

A

Nausea, retching, or vomiting
In PACU & w/in 24H postop

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2
Q

Post discharge nausea and vomiting (PDNV)

A

Symptoms that occur after discharge for outpatient procedures

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3
Q

_______ is a frequent cause of “unexpected hospital admission” after ambulatory surgery

A

Prolonged vomiting

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4
Q

T/F
Patients often rate PONV as worse than postoperative pain

A

True

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5
Q

POV affects __ % of all surgical patients.
The incidence of nausea is __%.
PONV in high-risk patients can be up to __%.

A

30
50
80

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6
Q

High Risk of PONV in Adults

A

Female
History of PONV or motion sickness
Nonsmokers
Younger
Type of surgery
Opioid analgesia

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7
Q

T/F
PONV can delay PACU discharge

A

True

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8
Q

Risk Score of PONV in Adults
(Apfel Simplified Risk Score)

A

2+ points = high risk

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9
Q

Postdischarge Nausea and Vomiting (PDNV)
risk factors

A

Female Gender
History of PONV
Age <50
Use of opioids in PACU
Nausea in PACU

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10
Q

Risk Score For PDNV in Adults

A
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11
Q

PONV
Potential Consequences

A

Increased cost
Increased admission rates (ambulatory care)
Suture dehiscence
Aspiration
Increased ICP
Pneumothorax

Patient Dissatisfaction

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12
Q

Factors that increase PONV

A

Hypercarbia, Gastric insufflation
Sympathetic stimulation
Methohexital
neostigmine?
Etomidate

Volatile anesthetics (↑ 2-3%)
(Limited to early postoperative period (30-60 mins))
Nitrous
Opioids
HypoTN, Dehydration, Fasting

Duration of anesthesia
Anesthetic technique
Experience of the anesthetist
Placement of airways

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13
Q

PONV
Surgeries that can increase risk

A

Cholecystectomy
Gynecologic (GYN)
Laparoscopic Procedures
Eye and Ear surgery
Shoulder?

In Children:
Strabismus surgery
Adenotonsillectomy
Inguinal, scrotal or penile procedures

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14
Q

On Apfel scoring, what is considered high and low risk?

A
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15
Q

Pediatric APFEL Score

A

0= 10%
1= 10%
2= 30%
3= 50%
4= 70%

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16
Q

Pathophysiology of PONV includes ____ & ____ mechanisms.

A

Central and Peripheral mechanisms

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17
Q

Five principal neurotransmitter receptors

A

-Anticholinergic/Muscarinic M1
-Dopamine D2
-Histamine H1
-5-hydroxytryptamine (5HT-3) serotonin
-Neurokinin 1 (NK1) or Substance P

All may be targets for prevention or treatment

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18
Q

Chemoreceptor Zone (CTZ)

A

4th ventricle in the area postrema

Dopamine D2 and 5HT-3

Susceptible to drugs and toxins (Chemo), anesthetic agents, opioids

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19
Q

T/F
The CTZ is protected by the blood brain barrier

A

False
not protected

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20
Q

Vestibular System

A

Histamine H1 and Muscarinic M1
Motion and equilibrium, middle ear

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21
Q

Vomiting Center

A

in nucleus tractus solitarius in postrema and lower pons

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22
Q

Physiologic Areas involved

A

Chemoreceptor Zone (CTZ)
Vestibular System
Vomiting Center
Cerebral cortex
GI tract

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23
Q

GIT features involved in N/V

A

-Afferent vagus nerve

-Enterochromaffin cells release serotonin

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24
Q

Strategies to Reduce Baseline Risk

A

-Avoid GA & use regional instead(A1)
-Adequate hydration(A1)
-Sugammadex instead of neostigmine (A1)
-Avoid nitrous in surgeries lasting over 1h (A1)
-Use propofol for induction & maintenance(A1)
-Avoid volatiles (A2)
-Minimize intraop (A2) & postop opioids (A1)

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25
Q

Opioid sparing/Postop pain control (ERAS)

A

Celebrex and Neurontin, Tylenol (IV or PO)
NSAIDS
Ketamine
Precedex
Robaxin

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26
Q

T/F
Avoiding hypertension will help prevent N/V.

A

False
avoid hypotension

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27
Q

Instead of GA, use….

A

regional
TIVA

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28
Q

T/F
Supplemental O2 concentration can help prevent PONV.

A

True

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29
Q

PONV
Treatment/Pretreatment

A

Scopolamine patch
Reglan
Decadron
Zofran
Propofol
Vistaril (Histamine 1)/Ephedrine 25/25 mg IM

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30
Q

Scopolamine patch
MoA
When to apply
When to remove

A

(competitive inhibitor at muscarinic sites)

2 hours prior to induction of anesthesia and remove 24 hours after use

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31
Q

Reglan MoA

A

Dopamine 2 antagonist

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32
Q

Decadron dosing

A

4-8 mg on induction (steroid)

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33
Q

Zofran
dose
MoA

A

4 mg at the end of surgery

(5-HT3 receptor antagonist)

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34
Q

used to treat Chemo-induced N/V (CINV)

A

Neurokinin 1/Substance P antagonists

Aprepitant PO (half-life of 40 hours)
Fosaprepitant IV
Rolapitant PO/IV (half life of 180 hours)

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35
Q

Phenergan (phenothiazine)

A
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36
Q

Butyrophenones for N/V

A

Droperidol
Haldol

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37
Q

(Effects of Opioids on N/V)
Incidence of PONV is greater than __% following balanced anesthesia

A

50

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38
Q

Opioids cause PONV by their effects on

A

the chemoreceptor zone (CTZ) in the area of the postrema of the brainstem

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39
Q

(Opioids)
Moving the patient (transport to the PACU) can exacerbate N/V d/t…

A

increased sensitivity of the vestibular system

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40
Q

CTZ receptors

A

dopamine (D2)
serotonin (5HT3)

histamine
opioid
muscarinic acetylcholine

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41
Q

these structures send neural projections to the vomiting center in the medulla

A

CTZ, vagal nerve, and vestibular organs

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42
Q

CTZ & vomiting center
location

A

CTZ: 4th ventricle of postrema (brainstem)

vomiting center: medulla

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43
Q

Opioid-Free Anesthesia
components

A

-Exparel (liposomal bupivacaine)
-Magnesium, Lidocaine IV
-Ketamine drip
-Propofol drip
-Antiemetics
-NSAID, Tylenol, Gabapentin, Celebrex

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44
Q

Enhanced Recovery After Surgery (ERAS)
components

A

-No NG tube!
-Carbohydrate rich clear drink
-Regional Anesthesia/Transabdominal Blocks (TAP block)

-TIVA
-Ketamine, Precedex, Lidocaine, Magnesium
-Gabapentin, Celebrex, Robaxin
-IV/PO Tylenol
-NSAIDs
-Exparel (liposomal bupivacaine)

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45
Q

Thermoregulation
3 phase process

A

Afferent thermal sensing
Central regulation or control
Efferent responses

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46
Q

Autonomic responses to heat & what mediates it?

A

sweating and active cutaneous vasodilation

sweating is mediated by postganglionic cholinergic nerves

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47
Q

Autonomic response to cold:

A

-Cutaneous vasoconstriction
(alpha-1 adrenergic receptors)

-Synergistically augmented by hypothermia-induced alpha-1 and 2 receptors

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48
Q

4 mechanisms of Heat Loss

A

Radiation
Conduction
Evaporation
Convection

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49
Q

1 & #2 source for heat loss

A

1: radiation

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50
Q

Radiation

A

Dissipation of heat to cooler surroundings

greatest heat loss (between 40-60%)

Depends on cutaneous blood flow & exposed surface area

Head

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51
Q

Convection

A

Airflow over exposed surfaces

Accounts for about 15-30% of intraoperative heat loss

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52
Q

Evaporation

A

Heat loss thru conversion of water → gas (body perspires)
8-10% of heat loss during surgery

Major open wound surgery

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53
Q

Conduction

A

Heat loss through physical contact with another object (cold surface; bed, mattress)

5% heat loss

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54
Q

Mechanisms of heat loss
%’s of heat loss

A

Radiation 40-60%
Convection 15-30%
Evaporation 8-10%
Conduction 5%

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55
Q

Hypothermia consequences

A

Wound infection & delayed healing
↑ O2 consumption (shivering)
↑ risk CV incidents (3x incidence of VT & cardiac events)
↑ sickling (sickle cell pts)
↓ platelet function
impairs coagulation cascade activation

(coagulopathy is the most well-studied complication of hypothermia)

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56
Q

Patients at high risk for hypothermia

A

Elderly: less subQ fat & altered hypothalamic fxn

Neonates

Intoxication: vasodilation & depressed heat regulatory center

Female

57
Q

Certain drugs that cause alterations in thermoregulation

A

vasodilators, NSAIDs and phenothiazines

58
Q

Neonates

A

-immature thermoreg center
-high surface area: body mass
-absent response to shivering (nonshivering thermogenesis)

59
Q

If temperature falls from 37 to 35 by how much does the risk of infection increase?

A

2-3 times

60
Q

How does hypothermia increase infxn risk?

A

Vasoconstriction

Decreased blood & O2 delivery to the wound
Decreased superoxide production

60
Q

If intraop temp falls to ___ degrees will increase the hospital stay by 2.5 days

A

35

61
Q

Perioperative period and Hypothermia
General anesthesia:

A

Peripheral vasodilation
altered thermoregulation
inability to generate heat by shivering

62
Q

(Neuraxial anesthesia)
Perioperative period and Hypothermia

A

d/t:
sympathetic blockade
muscle relaxation
lack of afferent sensory input → central thermoregulatory centers

63
Q

Perioperative period and Hypothermia
OR practices

A

Cold fluids and blood, prep solutions, exposure

64
Q

⭐️
fall in temperature during GA
3 phases:

A

1) initial rapid decrease ~0.5 - 1.5°C in ~30 min

2) slow linear reduction of about 0.3°C per hour

3) plateau phase as shown

65
Q

Chapter 13 in Anesthesia equipment read and understand how anesthesia affects the body

A

🤨😒

66
Q

Redistribution

A

-Internal distribution of body heat after GA induction

-Hypothermia after SAB or Epidural induction = added redistribution to legs

67
Q

If the temperature falls from 37 to 35.5, what is the average increase in estimated blood loss (EBL)?

A

~500 cc
Decreased activity of clotting factors

68
Q

T/F
Coag panels will show hypothermia induced coagulopathy

A

False
Labs run at inconsistent temps
you wont see hypothermia-induced coagulopathy on your coag panel

TEG (tests the strength of the clot) is usually warmed, but not mandatory

69
Q

Why is hypothermia BAD for the heart?
(As pt rewarms after surgery)

A

Shivering
Arrhythmias
Hypertension
Tachycardia

(note: hypothermia causes hypoTN and brady<3 but we’re talking about going from cold to warm in this instance)

70
Q

Compared to temperature of 35 degrees, normothermia is associated with a reduction in cardiac morbidity by ___%

A

55

71
Q

Hypothermia and the ECG
mild & moderate

A

Mild hypothermia: sinus brady

Moderate hypothermia: prolonged PR, widened QRS, prolonged QT

72
Q

Hypothermia and the ECG
severe

A

(below 32 degrees)
hypothermic hump/J-wave (Osborne)
elevation at the junction of the QRS and ST segments

73
Q

⭐️
MAC is decreased ___% per degree C decrease in core body temperature

A

5-7%

hypothermia DECREASES MAC

74
Q

Hypothermia
liver and renal fx

A

↓ renal blood flow and clearance

↓ hepatic blood flow can decrease metabolism

75
Q

Hypothermia (decreases/increases) Protein binding

A

increases

76
Q

Hypothermia & NMBs

A

Prolongs muscle relaxants

77
Q

These drugs can depress voluntary shivering that generates heat

A

Opioids and muscle relaxants

78
Q

During the first hour after induction of anesthesia, core body temperature can drop by 1.5° C due to what?

A

redistribution of body heat from core to periphery

79
Q

What is the definition of hypothermia?

A

core temp 36 C or less within 1H of start of case

80
Q

Which of the following is not an adverse effect of intraoperative hypothermia?

A

Increased risk of DVT/PE
Hypertension and tachycardia

81
Q

Peds
methods of heat loss %’s

A

Radiation 39%
Convection 34%
Evaporation 24%
Conduction 3%

(note: same order from greatest to least as adults; just diff %’s)

82
Q

Room temperature should be increased to at least ___℃ before nonfebrile neonates and infants arrive

A

26

83
Q

The 4 heat loss mechanisms

A
84
Q

How can we prevent or decrease the drop in patient temperature from redistribution after induction?

A

Increasing mean body temp
via
Pre-warming
usually need 30 min to be effective
(60 mins for large spinal surgeries)

85
Q

⭐️
most effective non-invasive method of warming a patient?

A

Forced air warming blanket

86
Q

⭐️
overall most effective method for warming a patient (invasive and noninvasive)?

A

Cardiopulmonary bypass

87
Q

Pre-warming

A

-prevent/decrease drop in temp from redistribution after induction
-Increases mean body temp

-30 min to be effective
(60 mins for large spinal surgeries)

88
Q

Where is the most accurate place to measure body temperature (closest to what the hypothalamus sees)?

A

Distal esophagus
45 cm from nose

89
Q

Temperature Monitoring
Sites

A

🏆 Pulmonary artery (PA)
Distal Esophageal
Skin
Nasopharynx
Rectal
Bladder
External auditory canal

90
Q

Distal Esophageal Temp monitor
optimal position

A

45cm from the nose

91
Q

Hyperthermia
definition

A

⬆️ body temp 2C/hr
-or-
Core > 38C

92
Q

Hyperthermia vs Hypothermia
which is uncommon in the OR?

A

hyperthermia

93
Q

⭐️
Hyperthermia
Usual causes

A

sepsis or overheating due to active warming

other causes:
Malignant Hyperthermia (MH) or other syndromes

94
Q

Manifestations of Hyperthermia

A

Increased metabolic requirements
Increased O2 consumption
Increased minute ventilation
Sweating and vasodilation
Tachycardia

95
Q

Conditions associated with Hyperthermia

A

MH and Neuroleptic Malignant Syndrome
Pheochromocytosis, sepsis
Transfusion reaction
Serotonin syndrome

96
Q

Malignant Hyperthermia

A

Inherited clinical syndrome

characterized by:
elevated core temperature
tachycardia
tachypnea
hypercarbia
muscle rigidity
rhabdomyolysis
acidosis
hyperkalemia

97
Q

⭐️
Malignant Hyperthermia
Underlying abnormality relates to

A

uncontrolled release of intracellular calcium from the sarcoplasmic reticulum

98
Q

Those susceptible to MH have a mutation of the _________ that allows ________ of calcium from SR

A

ryanodine receptor
uncontrolled release

99
Q

Malignant Hyperthermia
Leads to activation of:

A

muscle contractile elements
hypermetabolism

100
Q

MH
Mode of Inheritance

A

70% + of MH cases are linked to RYR1
(on chromosome 19)

The channel is the RYR1 because it binds to plant alkaloid ryanodine
MH is an inherited in an autosomal dominant manner
Does NOT skip generations

101
Q

RYR1

A

calcium channel in the membrane of the sarcoplasmic reticulum of skeletal muscle

MH = defective

102
Q

Why is it called the RYR1 receptor?

A

it binds to plant alkaloid ryanodine

103
Q

⭐️
T/F
MH can skip a generation

A

FALSE

104
Q

MH
Pathophysiology

A

abnormal/uncontrolled elevation of intracellular calcium levels in skeletal muscle

RYR1 calcium channel locked open

uncontrolled Ca release (ICF Ca high)

Continuous muscle activation

ATP breakdown (even more heat production)

SR Ca pump unable to reuptake Ca

105
Q

Family History significance in MH

A

Any Family history
especially first-degree relative

106
Q

MH
Associated skeletal muscle diseases:

A

Central core disease
King-Denborough syndrome
Multiminicore disease
Centronuclear myopathy
Congenital fiber-type disproportion
Native American myopathy

107
Q

MH
Specific Clinical Features

A

Uncontrolled, exaggerated, hypermetabolic state triggered by inhaled anesthetics and/or succinylcholine

Unexplained ↑ETCO2 during constant ventilation

Generalized & Masseter rigidity

↑ T (rarely >40 degrees C)

108
Q

MH
most sensitive and specific sign

A

Unexplained Increase in end-tidal carbon dioxide during constant ventilation

109
Q

Generalized rigidity vs Masseter muscle rigidity
which is more specific?

A

Generalized rigidity (HIGH specificity)

Masseter rigidity (not as specific)

110
Q

MH
Non-Specific Clinical Features

A

Tachycardia (earliest & most consistent sign, but not specific)

Tachypnea
Arrhythmias
Skin Mottling
Profuse sweating
Altered blood pressure

111
Q

Tachycardia as a sign in MH

A

earliest and most consistent sign, although not specific

112
Q

MH
Hyperkalemic Cardiac Arrest

A

Sudden hyperkalemic cardiac arrest after MH triggering agents in children with undiagnosed myopathy

especially dystrophinopathies, Duchenne or Becker’s muscular dystrophy

113
Q

T/F
Hyperkalemic Cardiac Arrest is a result of pathophysiologic changes typical of MH

A

False
not a result of this

114
Q

MH
Hyperkalemic Cardiac Arrest is r/t…

A

muscle membrane destruction leading to hyperkalemia

115
Q

MH
Hyperkalemic Cardiac Arrest
Treatment

A

Treatment for hyperkalemia

116
Q

Lab Findings of Acute MH

A
117
Q

MH
Preop Evaluation

A

Detailed medical history:
Previous surgery and issues
Family history
History of heat stroke or exaggerated reactions to heat and exercise

118
Q

MH
Preparing the anesthesia machine

A

1) Disable/remove/cover vaporizers

2) new breathing circuit & reservoir to y-piece of circle system

3) inflate (10L/min of fresh gas for up to 60-90 min; older machines 10L/min FGF for 20 min)

4) Change the CO2 absorbent

5) Activated charcoal filters to both limbs of the anesthesia breathing circuit before and during the procedure to reduce vapor [ ] to <5 ppm (increases washout period)

119
Q

MH
Med cart preparation

A

Cover/Tape the succinylcholine or remove it

120
Q

How does Dantrolene/Ryanodex work?

A

Direct-acting skeletal muscle relaxant

hydantoin derivative (anticonvulsant – Dilantin derivative)

Directly interferes w/ contraction
-inhibits Ca release from SR

? binds to the RYR1r

121
Q

Dantrolene/Ryanodex
temp control

A

Can lower temp in
-neuroleptic malignant syndrome
-thyroid storm

122
Q

MH Algorithm

A
123
Q

Most accurate diagnostic for MH

A

exposure of biopsied skeletal muscle to halothane, caffeine, and ryanodine

124
Q

MH
skeletal biopsy testing

A

-Thigh biopsy
-suspended in awater bath at 37C
-exposed to halothane, caffeine, or ryanodine

diagnosis of MH is based on:
Isometric contracture measured w/ strain gauge
(threshold & height of contracture)

125
Q

MH
muscle biopsy test statistics

A

highly sensitive and close to 100%

20% of positive results are false-positives

126
Q

Neuroleptic Malignant Syndrome
Signs/Symptoms

A

Muscle Rigidity and rhabdomyolysis, acidosis and tachycardia
Increased temperature
Depressed consciousness
Autonomic instability

127
Q

⭐️
Neuroleptic Malignant Syndrome
Underlying pathophysiology

A

R/t central dopaminergic blockade at hypothalamus

128
Q

Neuroleptic Malignant Syndrome
Triggers:

A

neuroleptics (Haldol)
antidopinergics
phenothiazines

other centrally acting drugs (Compazine, Reglan, Droperidol, and Phenergan)

129
Q

Neuroleptic Malignant Syndrome
Treatment

A

Benzodiazepines
Dopamine agonist (bromocriptine)

May respond symptomatically to dantrolene

130
Q

Serotonin Syndrome/Toxicity

A

excess serotonin in the CNS

131
Q

Serotonin Syndrome/Toxicity
S/S

A

Mental status changes

Autonomic hyperactivity (fever, tachy🩷, HTN, diaphoresis)

Neuromuscular abnormalities (tremor, hyperreflexia)

132
Q

Serotonin Syndrome/Toxicity
r/t pts on…

A

SSRIs, MAOI, tricyclics, amphetamines, Demerol

methylene blue
(acts as MAOI; increases serotonin levels, can be a trigger for serotonin syndrome)

133
Q

Serotonin Syndrome/Toxicity
Treatment

A

Active cooling
IV fluids
↑ anesthetic depth to ↓ autonomic hyperactivity

Serotonin antagonist
(Chloropromazine IV, Cyproheptadine PO)

134
Q

T/F
Avoid antipyretics in Serotonin Syndrome/Toxicity

A

True
Antipyretics have no role in this syndrome and should be avoided

Use NMB to help reduce rising body temperature

135
Q

Drugs that can Increase risk for Hyperthermia

A

↑ basal metab rate & heat production:
-Sympathomimetic drugs
-Monoamine oxidase inhibitors
-Cocaine
-Amphetamines
-Tricyclic antidepressants

↑ T by suppressing sweating:
-Anticholinergics
-Antihistamines

136
Q

How to treat Hyperthermia

A

Expose skin surfaces
Cooling blankets
Ice packs
Cool fluids
Antipyretics
Treat the cause
TURN OFF THE BAIR HUGGER

137
Q

Dantrium/Revonto vs Ryanodex

A