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N929 - Anesthesia Pharmacology > Anesthesia Pharmacology and Special Populations > Flashcards

Anesthesia Pharmacology and Special Populations Flashcards

1
Q

aging patients anesthesia considerations

A
  • fast growing population
  • less organ reserve
  • many prescriptions + medications (polypharmacy that could interact with our anesthetics)
  • more prone to adverse reactions to medications
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2
Q

body water % in elderly

A

decreases

50-55%

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3
Q

lean body mass % in elderly

A

decreases

12%

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4
Q

body fat % in elderly

A

increases
women 38-45%
men 36-38%

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5
Q

serum albumin in elderly

A

decreases

3.8 g/dL

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6
Q

kidney weight in elderly

A

decreases

80% that of a young adult

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7
Q

hepatic blood flow in elderly

A

decreases

55-60% that of a young adult

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8
Q

alpha 1 glycoprotein in elderly

A

increased, unknown mechanism

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9
Q

anesthesia plan for elderly requirements

A
  • meticulous preoperative assessment
  • detailed management of intraoperative variables and disease states
  • cautious titration of drug administration and doses [slower circ time; decrease doses]
  • age related increase in pharmacodynamic sensitivity to anesthesia agents [mechanism unknown]
  • additional monitor for anesthetic depth potentially indicated (BIS)
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10
Q

why are dose reductions for IV meds required in the elderly?

A
  • longer half-lives
  • 30% decrease dose Q10 years
  • increased brain sensitivity to narcotics
  • plasma drug concentrations immediately after injection usually higher due to decreased level of plasma proteins
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11
Q

optimization of post operative pain management in the elderly can be complicated by…

A
  • preexisting cognitive impairment

- fear of opioid related side effects

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12
Q

regional anesthesia for pain control in the elderly

A
  • anatomic changes in epidural and subarachnoid space
  • diameter and # of myelinated fibers decreased
  • increase permeability of dura and decreased volume of CSF
  • occlusion of intervertebral foramina with fibrous connective tissue
  • spread of block higher in elderly
  • regional can be patchy due to calcifications in the spinal column
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13
Q

muscle relaxants in the elderly

A
  • reduced skeletal muscle mass
  • onset of action delayed [slower circ time, increased amount of extrajunctional cholinergic receptors]
  • DOA extended (metabolism/elimination delayed due to decreased organ function)
  • antagonsim remains unchanged
  • reduced plasmacholinesterase (more reduction in males vs. females)
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14
Q

post-operative delirium

A
  • acute confusional state characterized by inattention, abnormal level of consciousness, thought disorganization, and a fluctuating course
  • one of the most common post-operative complications for elderly patients undergoing surgery
  • can be prevented in up to 40% of cases
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15
Q

pre-op review of medications in elderly

A
  • d/c or sub meds with potential drug interactions with anesthesia
  • d/c meds that increase surgical risk
  • identify meds to be discontinued based on Beer’s criteria
  • continue meds with withdrawal potential
  • avoid starting new benzos + reduce dose for those at risk for POD
  • avoid meperidine + morphine (active metabolites)
  • caution with antihistamines + meds with anticholinergic effects
  • consider starting B blocker/statin to decrease post-op CV adverse events
  • adjust renally excreted meds
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16
Q

drugs that can induce post-op delirium

A
  • tricyclic antidepressants
  • antihistamines
  • antimuscarinics
  • antispasmodics
  • first-generation antipsychotics
  • H2 receptor antagonists
  • skeletal muscle relaxants
  • antiemetics
  • corticosteroids
  • meperidine
  • sedative hypnotics
  • polypharmacy
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17
Q

main considerations for elderly population

A
  • renal impairment
  • decreased plasma protein [albumin]
  • reduced gastric motility and acidity
  • altered distribution
  • increased total body fat
  • decreased hepatic blood flow
  • decreased GFR
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18
Q

Pharmacology in obese patients influenced by…

A
  • different tissue distribution
  • hemodynamics
  • blood flow to tissue types (organs, adipose, splanchinic)
  • plasma composition
  • liver and kidney function
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19
Q

Pharmacokinetics in obese influenced by…

A
  • lipid solubility of drug

- diffusion through body compartments

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20
Q

things to consider when dosing medications for obese

A
  • volume of distribution for loading dose [IBW for drugs that are preferential for lean tissue; TBW for drugs with equal distribution to lean and adipose tissue]
  • clearance for maintenance dose
  • lean body weight (LBW)
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21
Q

what is lean body weight

A

measurement of weight in those who are obese that accounts for the extra development of muscle tissue to support large amounts of fat

22
Q

Thiopental in obese patients

A
  • dose on TBW

- prolonged DOA and 1/2 life

23
Q

propofol in obese patients

A
  • LBW for induction
  • TBW for maintenance
  • highly lipophilic, total clearance and Vd correlate well with TBW
24
Q

midazolam in obese patients

A
  • loading dose on TBW
  • maintenance dose on IBW
  • sedative effects correlate better to larger Vd and less to elimination
  • need higher dose to achieve initial therapeutic effects
25
Q

dexmedetomidine in obese patients

A
  • 0.2 mcg/kg/min

- lower than usual infusion rates recommended to minimize cardiac side effects

26
Q

succinylcholine in obese patients

A
  • dose based on TBW
  • large ECF compartment in obese
  • psuedocholinesterase activity increases with weight
27
Q

NDMRs in obese patients

A
  • dose based on IBW
  • prolonged DOA with TBW dosing
  • hydrophilic drugs given on IBW ensures more predictable recovery
28
Q

fentanyl in obese patients

A
  • weight based dose inconclusive
  • dosing based on TBW overestimates requirements
  • measure clearance has non-linear relationship to TBW
29
Q

sufentanil in obese patients

A
  • loading dose based on TBW
  • maintenance dose based on LBW and response
  • increased Vd and prolonged e1/2 life correlates with degree of obesity
30
Q

remifentanil in obese patients

A
  • dose based on IBW

- kinetics not effected by weight

31
Q

rectal admin in pediatrics

A

generally a slower absorption, commonly used in kids under 5 yo for sedation

32
Q

intranasal admin in pediatrics

A

faster onset, less offensive to children; can give midazolam and fentanyl via this route

33
Q

IM admin in pediatrics

A

not recommended because decreased muscle mass and pain that could potentially last for days; emergency drugs and pain medications can be given via this route

34
Q

IV admin in pediatrics

A

distribution of the drug depends on circulating blood elements, blood-tissue partition coefficients, distribution of blood flow

35
Q

drug distribution in pediatric patients

A
  • major proteins involved in binding drugs are albumin and alpha1 acid glycoprotein
  • much lower concentration in infants
  • presence of substance that can displace drug from proteins will alter pharmacology
  • agents that are highly protein bound will have an apparent smaller Vd
  • implications for blood gas and blood tissue coefficients for volatile anesthetics
36
Q

blood flow and pediatric pharmacology

A
  • smaller muscle mass and greater fat stores in neonates and infants
  • greater blood flow to central organs (brain, liver, heart, kidneys)
  • water soluble drugs may require higher doses (succ)
  • mismatch in tissue types effects duration of action
37
Q

other factors that affect pediatric drug distribution

A
  • integrity of BBB (decreased) = rapid uptake of anesthetics into CNS, higher brain blood flow
  • receptor affinity and sensitivity
  • developmental changes in hepatic metabolism (may not be mature yet)
  • change in renal function
38
Q

GFR at birth

A

40 mL/min

39
Q

GFR at 1 year of age

A

100 mL/min

40
Q

chemotherapy patients and anesthesia

A

focus on how the drugs will affect CV system, pulmonary function, and hematology to know how they will affect your anesthetic

41
Q

cisplatin

A
  • clinical use = lung cancer, breast cancer, bile duct cancer, ovarian cancer
  • toxicity = nephrotoxicity, peripheral neuropathy, nerve dysfunction
42
Q

methotrexate

A
  • clinical use = breast cancer, lymphomas, bladder cancer

- toxicity = myelosuppresion with neutropenia and thrombocytopenia

43
Q

bleomycin

A
  • clinical use = Hodgkin’s and non-Hodgkin’s lymphomas, bladder cancer
  • toxicity = pulmonary fibrosis
44
Q

doxorubicin

A
  • clinical use = lung cancer, lymphomas, ovarian cancer, thyroid cancer
  • toxicity = cardiotoxicity, myelosuppression
45
Q

cetuximab

A
  • clinical use = colon cancer, GI cancer

- toxicity = interstitial lung disease

46
Q

volatile anesthetics, barbs, and ketamine influence on cancer cell activity

A

suppress NK cell activity and can promote cancer cell mets

47
Q

nitrous oxide influence on cancer cell activity

A
  • reduces purine and thus DNA synthesis

- suppresses neutrophil chemotaxis, potentially facilitating the spread of cancer

48
Q

propofol influence on cancer cell activity

A
  • seems to exhibit protective effects through various mechanisms
  • anti-inflammatory effect
  • inhibition of COX-2 + reduction of PGE-2
  • weak beta adrenoreceptor binding
  • enhancement of antitumor immunity
  • NK function preservation
49
Q

opioids influence on cancer cell activity

A
  • may produce cellular and humoral immunosuppression

- most = morphine

50
Q

local anesthetics influence on cancer cell activity

A

shown to reduce metastatic burden

N929 - Anesthesia Pharmacology (12 decks)

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