1
Q
what is Cleviprex
A
Clevidipine
2
Q
Clevidipine
class/ categorie, uses
A
Class/Category: Dihydropyridine Calcium-Channel Blocker
Uses: HTN
3
Q
Clevidipine
MOA
A
Calcium-Channel Blocker: Inhibits Ca2+ influx into cardiac muscle and vascular smooth muscle
4
Q
Clevidipine
onset, peak, duration
A
Onset: 1-3 min
Peak: 2-10 min
Duration: 5-15 min
5
Q
Clevidipine
metabolism
A
plasma esterases
6
Q
clevidipine
CV effects
A
↓ BP, ↑ HR, ↓ SVR, ↔ preload, ↓ afterload, ↓/↔ inotropy
May experience reflex tachycardia or baroreceptor reflex
7
Q
Clevidipine
CNS effects
A
- May ↑ CBF, moderate cerebral vasodilator
- CO2 reactivity maintained
- HA
8
Q
Clevidipine contraindications
A
Allergy to soybeans, soy, eggs, or egg products; defective lipid metabolism
9
Q
Clevidipine relative contrainidations
1
A
severe aortic stenosis
10
Q
What conditions should you avoid using clevidipine for
3
A
- Avoid in heart failure with reduced EF,
- hyperlipidemic states,
- acute or chronic pancreatitis
11
Q
Does clevidipine cause tachyphylaxis OR rebound HTN
A
NO, not associated with tachyphylaxis or rebound HTN upon stopping
12
Q
clevidipine effect on renal blood flow
A
Increases renal blood flow
13
Q
What condition prolongs the effects of clevidipine?
A
Effect prolonged if pseudocholinesterase deficiency
14
Q
what is EmerPhed
A
Ephedrine
15
Q
Ephedrine
class/ category
A
Synthetic/Non-Catecholamine Adrenergic Agonist; Sympathomimetic
16
Q
Ephedrine
use
A
Treatment of hypotension
17
Q
Ephedrine
MOA
A
Adrenergic Agonist: Indirect >Direct effects (α1, β1, and β2)
18
Q
Ephedrine
dose
A
5-25 mg IV in 5-10 mg incremental doses
19
Q
Ephedrine
onset, peak, duration
A
Onset: <1 min
Peak: 2-5 min
Duration: 10-60 min
20
Q
Ephedrine
elimination
A
renal
21
Q
Ephedrine
CV effects
A
- ↑ BP, ↑ HR, ↑ CO
- ↑ SVR may be offset by β2-induced vasodilation
- ↑ myocardial O2 consumption
22
Q
Ephedrine
Pulm effects
A
Bronchodilation (β2)
23
Q
Ephedrine
CNS effects
A
- Crosses BBB, CNS excitation
- Mydriasis
24
Q
What does ephedrine do to renal and splanchnic blood flow?
A
Decreases renal and splanchnic blood flow
25
What does repeat dosing with ephedrine cause?
Tachyphylaxis with repeat dosing (due to **depleted** NE stores), may require increasing doses
26
Ephedrine does what to MAC requirements
Increases MAC requirements
27
Ephedrine may interact with which medications and cause what?
May interact with MAO-inhibitors → hypertensive crisis or serotonin syndrome
28
use this medication cautiously with questionable coronary perfusion
ephedrine
29
What is Adrenalin
Epi
30
Epinephrine
| class/ category, uses
Class/Category: Adrenergic agonist
Uses: Cardiac arrest; anaphylaxis; bradycardia; bronchospasm; cardiogenic or vasodilatory shock
31
Epi
| MOA
Adrenergic Agonist: Direct-acting α1, β1, β2
32
Epi
| dose-infusion
Infusion:
β effects: 0.01-0.03 mcg/kg/min
β & α effects: 0.03-0.15 mcg/kg/min
α effects: 0.15-0.3 mcg/kg/min
33
Epi
| bolus dose-cardiac arrest
Cardiac arrest (pulseless):
1 mg IV/IO or 2-2.5 mg ETT (diluted in 5-10 mL Sterile Water), may repeat every 3-5 min
01 mcg/kg IV/IO or 0.1 mg/kg ETT; may repeat initial dose up to 10x, repeating every 3-5 min
IV/IO/ETT doses up to 0.2 mg/kg may be effective[
34
Epi
| dose-anaphylaxis
Anaphylaxis:
5-10 mcg IV bolus, if hypotension, titrate to effect[2]
1-1 mg IV bolus, if CV collapse[2]
Infusion 5-10 mcg/min (0.01 mcg/kg/min),[2] may increase up to 20 mcg/min[4]
If laryngeal edema without hypotension, administer SubQ[2]
Avoid IV administration if normal BP
35
Epi
| Dose-bradycardia
Bradycardia:
01 mg/kg IV/IO or 0.1 mg/kg ETT
36
Epi
| Peds-cardiac arrest and vasoactive doses
Cardiac arrest: 0.01-0.02 mg/kg
Vasoactive (α & β effects) 0.05-2 mcg/kg/min
37
Epi
| Peds bronchospasm and bradycardia doses
Bronchospasm: 5-10 mcg/kg IV/SQ
Bradycardia (neonatal): 0.01-0.03 mcg/kg IV or 0.05-0.1 mcg/kg ETT (1:10k)
38
Epi
| onset, peak, duration
Onset: < 1 min
Peak: 1-2 mins
Duration: 5-10 min
39
Epi
| Metabolism
Enzymatic degradation by COMT and MAO
40
Epi
| CV effects
* ↑ HR, ↑ CO, ↑ contractility, ↑ conduction velocity, ↑ ventricular relaxation
Initial ↑ HR → ↓ HR (baroreceptor reflex)
* ↑ BP, ↑ SVR, ↑ preload, ↑ afterload
* ↑ myocardial O2 demand; possible ↓ myocardial O2 supply, may → myocardial ischemia
41
Epi
| pulm effects
Bronchodilation
May ↑ PAP
42
Epi
| CNS effects
* Cerebral arteriolar vasoconstriction
* Risk for stroke and cerebral hemorrhage
43
Epi's effects on hepatosplanchnic, renal blood flow and what does it cause to tissue O2 exchange and lactate clearance?
↓ hepatosplanchnic and renal blood flow → ↓ tissue O2 exchange and ↓ lactate clearance
44
epi does what to renin secretion
↑ renin secretion
45
Epi is not recommended for what type of medication overdose
Not recommended for β-blocker overdose
46
T/F epi can cause hyperglycemia and mydriasis?
True
47
Caution use in epi for what condition?
pulm HTN
48
what could a supratherapeutic does of Epi cause?
Supratherapeutic dose may → acute heart failure, pulmonary edema, arrhythmia, HTN, myocardial ischemia
49
T/F Epi causes tachyphylaxis
False, no tachyphylaxis
50
what is Brevi-Bloc
Esmolol
51
Esmolol
| class/ category
Selective Adrenergic Antagonist; Class II antiarrhythmic
52
esmolol
| uses
HTN, dysrhythmia, myocardial ischemia, β-blockade continuation; blunt SNS response to noxious stimuli
53
esmolol and metoprolol
| MOA
Adrenergic Antagonist: β1 (cardioselective)
54
Esmolol
| dose (bolus and infusion)
Bolus: 0.5-1 mg/kg over 1 min
Infusion: 50-300 mcg/kg/min
55
Esmolol
| onset, peak, duration
Onset: 1-2 min
Peak: 5 min
Duration: 10-15 min
56
Esmolol
| metabolism
Non-specific plasma esterases
57
Esmolol and metoprolol
| CV effects
* ↓ BP, ↓ HR, ↓ contractility, ↓ conduction velocity, ↑ ventricular relaxation
* ↓ myocardial O2 demand
58
Esmolol and metoprolol
| GI effects
N/V/D
59
T/F esmolol and metoprolol might mask signs of hypoglycemia
True
60
T/F esmolol does not cause pain on injection
FALSE, pain on injection
61
what happens with large doses of esmolol or metoprolol
Large doses may have β2 antagonist effect
62
esmolol and metoprolol are not recommended for treatment what overdose
Not recommended for treatment of Phenylephrine overdose
63
T/F to avoid esmolol or metoprolol if sinus brady,
what could occur?
TRUE! Avoid if sinus brady, cardiogenic shock
64
Relative contraindications for esmolol and metoprolol
Relative contraindication: Reactive or obstructive airway disease (especially if **high** dose)
65
contraindications for esmolol and metoprolol
| 2-cardiac
Preexisting AV block (greater than 1st degree), acute/ uncompensated HFrEF
66
what is apresoline
hydralazine
67
hydralazine
| class/ category and uses
Class/Category: Antihypertensive
Uses: Treatment of hypertension
68
hydralazine
| MOA
Mechanism of Action:
* Not well understood
* Direct systemic vasodilator **arterial** > venous relaxation
69
hydralazine
| dose
Bolus: 2.5-20 mg IV
70
Hydralazine
| onset, peak, duration
Onset: 2-20 min
Peak: 10-80 min
Duration: Up to 12 hr
71
esmolol
| metabolism and elimination
Metabolism: Hepatic
Elimination: Renal
72
hydralazine
| CV effects
* ↓ BP, ↑ HR, ↑ CO, ↓ SVR, ↑ contractility
Stimulates baroreceptor → reflex **vagal** activity, may include **bradycardia**
* May cause CHF, angina
73
hydralazine
| pulm effects
May alter reactivity of pulmonary vasculature
74
hydralazine
| CNS effects
* ↑ CBF, ↑ ICP (unless MAP markedly reduced)
* **Inhibits** CBF autoregulation
* HA, dizziness, tremors
75
hydralazine
| GI effects
nausea
76
what type of blood flow does hydralazine effect and what does it do?
↑ coronary, cerebral, renal, and splanchnic blood flow
77
hydralazine reversal agent
Phentolamine
78
T/F hydralazine may cause lupus-like syndrome (usually with renal involvement)
TRUE!
79
hydralazine is not recommended for patients with what disease and what could that cause?
Not recommended for patients with coronary artery disease, myocardial ischemia
80
what is Trandate
Labetolol
81
Labetalol
| class/ category and uses
Class/Category: Non-Selective Adrenergic Antagonist
Uses: HTN, tachycardia
82
Labetolol
| MOA
Adrenergic Antagonist: Combined, α1 (selective), and β1 & β2 (non-selective)
83
Labetolol
| dose
Bolus:
2.5-10 mg IV bolus over 2 min, then 5-20 mg every 10 min until desired response (typically 5-20 mg)
84
Labetolol
| onset, peak, duration
Onset: 1-5 min
Peak: 5-10 min
Duration: 2-6 hr, dose dependent
85
Labetolol
| metabolism
hepatic
86
Labetolol
| CV effects
* ↓ BP, ↓ HR, ↓ SVR, ↔ CO, ↓ Contractility
* May cause reflex tachycardia
* CHF
* Heart block
87
Labetolol
| Pulm effects
Bronchospasm
88
T/F Labetolol can cause orthostatic hypotension
TRUE!
89
what condition should labetolol be avoided with?
Avoid with symptomatic asthma
90
labetolol effects and ratio
Β:α effects, 7:1 by IV route
91
what is lopressor
metoprolol
92
metoprolol
| class/ category and use
Class/Category: Selective Adrenergic Antagonist
Uses: HTN, myocardial ischemia, β-blockade continuation
93
metoprolol
| dose
Bolus: 1-5 mg IV, every 2-5 min until desired response, up to 15 mg
94
metoprolol
| onset, peak, duration
Onset: 1-5 min
Peak: 20 min
Duration: 1-4 hr
95
metoprolol
| metabolism
hepatic
96
what is Cardene
Nicardipine
97
Nicardipine
| class/ category and use
Class/Category: Dihydropyridine Calcium-Channel Blocker
Uses: HTN, perioperative BP management
98
Nicardipine
| MOA
Calcium-Channel Blocker: Inhibits Ca2+ influx into cardiac muscle and vascular smooth muscle
99
Nicardipine
| Dose (bolus and infusion)
Bolus: 100-400 mcg IV
Infusion: 2-5 mg/hr IV, up to 15 mg/hr IV (1-2 mcg/kg/min, increased to 7.5 mcg/kg/min as needed)
100
Nicardipine
| onset, peak, duration
Onset: 1-3 min
Peak: 5-10 min
Duration: 30-60 min
101
Nicardipine
| metabolism
Hepatic CYP3A4
102
Nicardipine
| CV effects
## Footnote
5
* ↓ BP, ↑/↔ HR, ↓/↔ CO, ↓ afterload, ↓/↔ contractility
* May experience reflex tachycardia or baroreceptor reflex
* Moderate to no myocardial depression
* Marked coronary artery and peripheral artery dilation
* Marked peripheral artery dilation
103
Nicardipine
| CNS effects
## Footnote
4
* ↑ CBF, ↑ CBV
* Moderate cerebral vasodilator
* CO2 reactivity maintained
* HA
104
what type of edema does nicardipine cause
peripheral edema
105
nicardipine increases blood flow where
Increases renal blood flow
106
Nitroglycerin
| class/ category and MOA
Class/Category: Nitrovasodilator
Mechanism of Action: Generates Nitric Oxide (NO)
107
Nitro
| uses
Uses:
Myocardial ischemia; Heart failure with reduced EF; Controlled hypotension
108
Nitro
| dose-bolus
Bolus: 5-100 mcg
109
Nitro
| infustion dose
Infusion:
Start at 5 mcg/min, increase by 5 mcg/min every 3-5 minutes until desired effect; if no response at 20 mcg/min, may increase by 10-20 mcg/min every 3-5 min
110
Nitro
| onset, peak, duration
Onset: 2-5 min
Peak: 1-2 mins
Duration: 5-10 min
111
Nitro
| metabolism
Hepatic
112
Nitro
| CV effects
* ↓ BP (↓ preload),↑ HR, ↓ CO
* Stimulates baroreceptor
* Coronary artery vasodilator, improves myocardial supply-demand balance
113
Nitro
| pulm effects
May ↓ PaO2
↓ PAP
114
Nitro
| CNS effects
* ↑ CBV
* ↑ ICP (but less than SNP)
* HA
115
T/F nitro inhibits platelet aggregation
TRUE!
116
Do not use Nitro with in how many hours of what type of medications AND what could it cause?
Do not use within **24 hours** of erectile dysfunction drugs (PDE5 inhibitors)
May result in
* significant hypotension,
* myocardial ischemia,
* myocardial infarction,
* death
117
Avoid in patients with what SBP, HR, and what?
Avoid in patients with SBP < 90 mmHg, HR < 50 or > 100, or RV infarction
118
Nitro is not recommended in what type of patients?
Not recommended for patients with hypertrophic obstructive cardiomyopathy, or in the presence of severe aortic stenosis
119
Nitro should be used cautiously in what type of patients and what could it cause?
Caution in hypovolemic patients, severe hypotension may compromise coronary perfusion pressure
120
what could nitrite metabolites cause?
Nitrite metabolite may oxidize ferrous ion in hemoglobin to methemoglobin → methemoglobinemia (especially in patients with hepatotoxicity or receiving high doses)
121
T/F Nitro and nitroprusside is methemoglobin-inducing
True!
122
what is Nipride/ SNP
Sodium Nitroprusside
123
Nitroprusside
| class/ category
Nitrovasodilator; Nonselective peripheral vasodilator
124
Nitroprusside
| Uses
Hypertensive emergency; controlled hypotension; aortic/cardiac surgery; cardiogenic shock
125
Nitroprusside
| MOA
Nitric Oxide (NO) donor, Direct-acting
126
Nitroprusside
| Dose (infusion/ duration)
* Infusion: Start at 0.3 mcg/kg/min and increase up to 10 mcg/kg/min
* Duration of 10 mcg/kg/min infusion not to exceed 10 min
127
Nitroprusside
| onset, peak, duration
Onset: Seconds
Peak: 2 min
Duration: 1-5 min
128
Nitroprusside
| metabolism and toxic metabolites
Metabolism: Interacts with oxyhemoglobin, dissociating immediately to methemoglobin, releasing cyanide and NO
Toxic metabolites: Cyanide, thiocyanate (especially in renal disease)
129
Nitroprusside
| CV effects
* ↓ BP(↓ Preload, ↓ Afterload), ↑ HR, ↑ contractility
* Stimulates baroreceptor
* ↑ myocardial O2 demand
* ↓ coronary perfusion pressure
130
Nitroprusside
| Pulm effects
* ↓ PaO2, ↑ pulmonary shunt
* ↓ PVR
131
Nitroprusside
| CNS effects
* ↑ CBF, ↑ CBV
* ↑ ICP, may be offset by slowing infusion
132
T/F nitroprusside contains cyanide
TRUE
133
Is Nitroprusside associated with coronary steal?
YES!
134
What does Nitroprusside do to platelet aggregation
Inhibits platelet aggregation
135
Nitroprusside increases bleeding time at what rate?
↑ bleeding time at > 3 mcg/kg/min
136
what are possible nitroprusside antidotes
| 3
* Sodium thiosulfate,
* Hydroxocobalamin,
* Sodium nitrite
137
Nitropruside relative contraindication?
## Footnote
hint: cardiac
Relative contraindication: Acute myocardial ischemia
138
What is levophed
Norepinephrine!
139
Norepi
| class/ cateory
Adrenergic agonist; Direct-acting α1, α2, β1 agonist (minimal β2 effect)
140
Norepi
| uses
* Vasopressor
* Septic, cardiogenic, or refractory shock
* Distributive shock
* Anaphylaxis
141
Norepi
| MOA
Adrenergic agonist; Direct-acting α1, β1, β2 agonist
142
Norepi
| Dose
Infusion: 1-20 mcg/min(0.01-0.2 mcg/kg/min)
143
Norepi
| onset, peak, duration
Onset: < 1 min
Peak: 1-2 mins
Duration: 2-10 min
144
Norepi
| metabolism
* Primary adrenergic reuptake
* secondary enzymatic degradation by COMT and MAO
145
Norepi
| CV effects
* ↑ HR, ↑ contractility (less than Epi); ↑ conduction velocity, ↑ ventricular relaxation
* ↑ BP, ↑ SVR (more than Epi); ↑ venous return, ↑ afterload
* Arrhythmogenic potential (less than Epi)
* ↑ myocardial O2 demand; possible myocardial ischemia if flow-limiting stenosis
146
Norepi
| pulm effects
↑ PAP
147
Norepi effects on which bloodflow (2), less than what medication, and effect on tissue O2 and lactate
↓ hepatosplanchnic and renal blood flow (less than Epi) → ↓ tissue O2 exchange and ↓ lactate clearance
148
Norepi could cause what type of vasoconstriction and what could it cause?
Renal artery vasoconstriction may → oliguria, renal failure
149
T/F Norepi is okay to use with RV dysfuction/failure
FALSE, caution with RV dysfunction/failure
150
T/F concern for end-organ hypoperfusion and ischemia with norepi
TRUE!
151
what is Neo-Synephrine?
Phenylephrine
152
Phenylephrine
| class/ category
Synthetic/Non-catecholamine Adrenergic Agonist; Sympathomimetic
153
Phenyl
| use and MOA
Uses: Treatment of hypotension
Mechanism of Action: Adrenergic Agonist: Direct α1
154
Phenyl
| dose (bolus and infusion)
Bolus: 40-200 mcg bolus
Infusion: 20-200 mcg/min or 0.15-0.75 mcg/kg/min
155
Phenyl
| onset, peak, duration
Onset: <1 min
Peak: 1 min
Duration: 15-20 min
156
Phenyl
| metabolism
hepatic
157
Phenyl
| CV effects
* ↑ BP, ↑ SVR, ↑ Preload, ↑ Afterload
* Stimulates baroreceptor → reflex vagal activity, may include bradycardia
* ↓ CO
158
phenyl
| Pulm effects
↑ PAP
159
reversal agent for phenylephrine
Phentolamine
160
Phenylephrine does what to renal, splanchnic, cutaneous, mesenteric, and skeletal muscle blood flow
Decreases
161
T/F Tachyphylaxis with infusions may require upward titration of infusion dosing of phenylephrine
True
162
what is phenylephrine NOT recommended for treatment of?
Not recommended for treatment of septic shock, unless serious arrhythmia with norepinephrine, high CO, or require salvage therapy
163
How does phenylephrine effect vessel constriction?
Venoconstriction > arterial constriction
164
what is Vasostrict?
Vasopressin
165
vasopressin
| class/ category and uses
Class/Category: Nonadrenergic Vasopressor
Uses: Treatment of hypotension, shock
166
Vasopressin
| MOA
Nonadrenergic Agonist; Direct acting, V1
167
Vasopressin
| dose (bolus and infusion)
Bolus: 1-2 units IV (perioperative hypotension)
Infusion: 0.01-0.1 units/min (shock states)
168
vasopressin
| onset, peak, duration
Onset: 1-5 min
Peak: 5 min
Duration: 10-30 min
169
Vasopressin
| elimination
hepatic/ renal
170
vasopressin
| CV effects
## Footnote
5
* ↑ BP, ↔ HR, ↔ Contractility, ↓ CO,↑ SVR
* ↑ Myocardial O2 consumption
* Arrhythmias
* Coronary artery vasoconstriction → angina pectoris, EKG changes suggestive of myocardial ischemia, MI
* Risk for cardiac arrest
171
Vasopressin
| CNS effects
↑ CBF, ↔ ICP
172
vasopressin
| GI effects
↑ peristalsis → abdominal pain, N/V
173
vasopressin does what to splanchnic, renal, coronary, and peripheral vascular beds and what is the risk associated?
Vasoconstricts splanchnic, renal, coronary, and peripheral vascular beds → ischemia risk
174
where does vasopressin shunt blood?
Shunts blood to cerebral, cardiac, and pulmonary vascular beds
175
what does vasporession do to cutaneous vessels and the symptoms seen?
Cutaneous vasoconstriction → pallor
176
what does vasopresson do to uterine smooth muscle?
uterine smooth muscle contraction
177
T/F caution with CAD with vasporessin
True
178
prolonged use of vasopresson can cause what?
Prolonged use may decrease effect
179
Vasopression is not recommended for the treatment of what?
not recommended for the treatment of LAST
180
what is the most potent arterial vasoconstrictor?
Vasopressin
181
V1-what G coupled receptor and action
V1 (Gq) – Vascular smooth muscle → Arterial vasoconstriction
182
V1-what G coupled receptor and action
183
V3-what G coupled receptor and action
V3 (Gq) – Anterior pituitary → Corticotropin release
