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Pharmacology I - CP > Antiemetics > Flashcards

Antiemetics Flashcards

(63 cards)

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1
Q

Percent in children that PONV occurs

A

25-39% in children over the age of 3

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2
Q

Increased anesthetic duration ____ risk

A

increases

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3
Q

At risk patients benefit from _____

A

one or more prophylactic measures

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4
Q

Risk factors for PONV

A

females, history of PONV or motion sickness, nonsmoker, younger, apprehension, gastroparesis, recent food ingestion

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5
Q

Surgical risk factors for PONV

A

increased duration of anesthesia, type of surgery: laparoscopy, eye, T&A, breast, GU/GYN, preop administered opioid, inhalational induction, volatile anesthetics, NO

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6
Q

each 30 minute increase in duration increases PONV risk by ____

A

60%

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7
Q

Postanesthetic related factors for PONV

A

ambulation, postural hypotension, uncontrolled pain, postop opioid administration, early oral intake, lower FiO2 concentration, reversal agents (neostigmine >2.5mg)

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8
Q

SAMBA guidelines

A
  1. identify pts at risk
  2. employ management strategies
  3. employ one or more prophylactic measures for moderate risk
  4. use multiple interventions for high risk
  5. administer antiemetic to kids at high risk
  6. provide antiemetic with PONV who did not receive prophylactic therapy or prophylaxis failed
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9
Q

Apfel score

A

risk score 0-4
3 or 4 high risk- use multi-modal strategy

female (1)
nonsmoker (1)
hx of PONV (1)
postop opioids (1)

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10
Q

What is the benefit of combination therapy?

A

Targets multiple receptors

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11
Q

What kind of agents should be used in combination therapy?

A

a rapid onset agent + longer duration of action agent

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12
Q

How can vomiting be triggered?

A

directly or indirectly

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13
Q

Direct pathways that trigger vomiting

A

noxious stimuli, toxins, drugs, irritants

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14
Q

Indirect pathways that trigger vomiting

A

stimulation of vomiting center in medulla oblongata

  • cerebral cortex/thalamus
  • vestibular apparatus
  • vagal afferent GI tracts
  • chemoreceptor trigger zone (CTZ)
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15
Q

What is significant about the chemoreceptor trigger zone?

A

it is close to the medulla in the floor of the 4th ventricle, not protected by BBB

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16
Q

Once activated, efferent motor nerves travel thru ___

A

CN V, VII, IX, X, XII, sympathetic, and spinal nerves to stimulate various parts of the body to trigger vomiting

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17
Q

What receptors are thought to be activated?

A
  • histamine
  • muscarinic
  • opioid
  • dopamine (D2)
  • 5-hydroxytryptamine (serotonin)
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18
Q

What is the most common class of antiemetics?

A

serotonin receptor antagonist

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19
Q

Which subtype of 5-HT receptor mediates vomiting and where is it found?

A

subtype 3; 5-HT3 receptor in the GI tract and brain (CTZ and NTS)

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20
Q

Trigger zone of serotonin activated by ___

A

anesthetics and opioids

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21
Q

Serotonin CV effects

A

vasoconstrictor, vasodilator effect in heart is endothelium dependent

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22
Q

Serotonin respiratory and GI effects

A

resp: increased airway resistance
gi: release of ACh in myenteric plexus increases peristalsis

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23
Q

What kind of receptors are 5- HT3?

A

gated Na+/K+ channels

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24
Q

When are the serotonin receptor antagonists best administered?

A

end of surgery

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25
Example of a serotonin receptor antagonist
Ondansetron, Palonosetron, Dolasetron
26
Dose of Ondansetron
PO 4 or 8mg IV 4mg 0.1 mg/kg if <40 kg (kids)
27
Half life and onset time of Zofran
Half life: 4 hours | Onset: 30 minutes
28
Metabolism of Zofran
liver by hydroxylation and conjugation | no need to adjust for renal
29
Dose of Palonosetron
0. 75 mg for PONV | 0. 25 chemo-induced
30
Half life of Palonosetron
40 hours
31
Dose of Dolasetron
12.5 mg IV
32
MOA of Dolasetron
reduce activity of vagus nerve to limit activation of the vomiting center in medulla oblongata
33
When should you administer dolasetron?
within 15 minutes before the end of anesthesia
34
Active metabolite of dolasetron
hydrodolasetron
35
Droperiol is part of what class and MOA
butyrophenone/dopamine receptor antagonist MOA: blocks dopamine receptors that contribute to development of PONV
36
Dose of droperidol
0.625-1.25 mg IV or IM
37
What does droperidol cause?
QT interval prolongation
38
What class and MOA of prochlorperazine (compazine)
antipsychotic/antiemetic MOA: affects multiple receptors - histaminergic, dopaminergic (D2 blockade), muscarinic
39
Dose of compazine
5-10 mg IM/IV before induction
40
What kind of side effects could prochlorperazine cause?
extrapyramidal and anticholinergic side effects (muscarinc side effects) sedation, blurry vision, hypotension, dizziness, neuroleptic malignant syndrome, restlessness, dystonia
41
What class is metoclopramide in and MOA?
dopamine receptor antagonist MOA: centrally acting as dopamine receptor antagonist in CTZ, peripherally acting as cholinomimetic in GI tract
42
Which antiemetic is a good choice for patients at risk of aspiration?
metoclopramide (reglan)
43
Dose for metoclopramide
10 mg IV or 0.1 - 0.25 mg/kg q 6-8h
44
When should reglan be avoided?
pheochromocytoma (can cause HTN crisis), parkinson's, seizure, GI obstruction (can cause extrapyramidal effects)
45
What class and MOA of Aprepitant (Emend)
neurokinin-1 receptor antagonist MOA: NK-1 antagonist inhibit substance P at central and peripheral receptors
46
Dosing considerations with Emend
want to decrease dose of zofran if given together because Emend increases activity of serotonin receptor antagonists if administered with dexamethasone, reduce dose by half to keep dexamethasone concentrations
47
Effects of Emend on oral contraceptives
makes ineffective for 28 days!
48
MOA of dexamethasone (decadron)
long acting corticosteroid with anti-inflammatory and immunosuppressant properties
49
Dose of Dexamethasone
4-10mg IV | peds: 0.2 - 0.5 mg/kg IV
50
Contraindications with Dexamethasone
uncontrolled infections, known hypersensitivity, cerebral malaria, systemic fungal infection, concurrent treatment with live virus vaccine
51
Class and MOA of Dimenhydrinate
histamine1 receptor antagonist MOA: competes with histamine at H1 receptor sites in GI tract, blood vessels, and respiratory tract, blocks CTZ, depresses labyrinthine function and vestibular stimulation
52
Dose of dimenhydrinate
50-100mg IV/IM q4h (max dose 100mg q4h)
53
Promethazine MOA
antihistamine (H1 antagonist) and anticholinergic/muscarinic blocking effects
54
Dose of promethazine
12.5-25 mg q4-6h IM route preferred low dose (5-10) for prophylaxis/rescue
55
Class and MOA of Scopolamine
muscarinic antagonist/anticholinergic inhibits action of Ach at parasympathetic sites in smooth muscle, CNS, and secretory glands, competitively blocks binding of ACh
56
What allows anticholinergics to bind to Ach receptors?
ester linkage
57
What can you give to reverse scopolamine?
physostigmine | 0.01-0.03 mg/kg
58
Dose of scopolamine
1.5 mg transdermal patch behind the ear the evening before surgery
59
Adverse effects of scopolamine
dry mouth, increased thirst, dry skin, constipation, drowsy, dizzy, blurry, dilated pupils, light sensitive
60
ephedrine dose
10-25mg IV for NV associated with postural hypotension 0.5 mg/kg IM at end of surgery = droperidol 40mcg/kg IM minimizes NV with less sedation
61
Midazolam dose
peds: 50-75mcg/kg IV adult: 2mg IV
62
What is a good combination for midazolam in kids
midazolam + dexamethasone = zero incidence of PONV in kids undergoing strabismus surgery
63
what nonpharmacological intervention can we use for NV?
P6 acupuncture point stimulation | isopropyl alcohol inhalation

Pharmacology I - CP (8 decks)

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