Cumulative Final (Exam 4) Flashcards by Brandon Simpson

Max dose for neostigmine and edrophonium?

Neostigmine: 50 mcg/kg or 5 mg
Edrophonium: 1 mg/kg

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What is the dosage of edrophonium?

1 mg/kg

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What is the formula for glycopyrrolate to be used with a NMB reversal drug?

0.2 mg of glycopyrrolate / mg of neostigmine

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What drugs would be coupled with NMBD reversal agents to prevent adverse side effects from these drugs?

Anti-cholinergic / Anti-muscarinics

Atropine for edrophonium
Glycopyrrolate for neostigmine and pyridostigmine

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What is the dose of atropine for use with edrophonium?

10 mcg/kg

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What is the max dose for glycopyrrolate?

1 mg

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When is sugammadex contraindicated?

Renal impairment on dialysis

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What is the Sugammadex dose for a moderate block?

2 mg/kg

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What is the Sugammadex dose for a deep block?

4 mg/kg

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Dose Dependent Effects of Lidocaine if plasma lidocaine concentration is 1-5 mcg/ml.

Analgesia

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Dose Dependent Effects of Lidocaine if plasma lidocaine concentration is 5-10 mcg/ml.

Circum-oral numbness
Tinnitus
Skeletal muscle twitching
Systemic hypotension
Myocardial depression

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Dose Dependent Effects of Lidocaine if plasma lidocaine concentration is 10-15 mcg/ml.

Seizures
Unconsciousness

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Dose Dependent Effects of Lidocaine if plasma lidocaine concentration is 15-25 mcg/ml.

Apnea
Coma

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Dose Dependent Effects of Lidocaine if plasma lidocaine concentration is >25 mcg/ml.

Cardiovascular Depression

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Which 3 LA will have the highest protein binding?

Levobupivacaine (>97%)
Bupivacaine (95%)
Ropivacaine (94%)

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Lipid solubility correlates to _______ of the drug.

Which LA has the highest lipid solubility?

potency

Tetracaine

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MOA of Local Anesthetics

Binds to voltage-gated Na+ channels (must be inactivated and closed)
Block/inhibit Na+ passage in nerve membranes

LA must be non-ionized and lipid-soluble to go through the cell membrane and block the Na+ gated channel from within the cell.

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Which nerve fibers are blocked most rapidly?

Pre-ganglionic B fibers (SNS)

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Which patient population will have increased sensitivity LA and require a smaller dose?

Pregnancy

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List the uptake of Local Anesthetics Based on Regional Anesthesia Technique from highest blood concentration to lowest blood conc.

“I Tried Coffee Plus Espresso, But Shaky Start!”

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Which LA will metabolize the fastest?

Chloroprocaine d/t the 0% of protein binding.

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Metabolism of Amides.
Location of Metabolism:
Most rapidly metabolized drug:
Intermediate:
Slow:

Location of Metabolism: Microsomal enzyme (Liver)
Most rapidly metabolized drug: Prilocaine
Intermediate: Lidocaine, Mepivacaine
Slow: Levobupivicaine, Bupivacaine, Ropivacaine

Metabolism is dependent on protein binding! Less protein bound → higher plasma conentration → more metabolized

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Metabolism of Esters?
Exception?

Hydrolyzed by cholinesterases in plasma, except cocaine which is metabolized by the liver.

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What is the metabolite of esters?

What is the significance of this metabolite?

ParaAminoBenzoic acid (PABA)
Allergic reactions

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What is Lidocaine max infiltration dose (plain and w/ epi)?

Maximum infiltration dose: **300 mg plain** **500 mg with EPI** (*Rate of distribution is slower with epinephrine, so we can give more lidocaine.*)

Prilocaine metabolite. What is the issue with this metabolite?

Metabolite: Ortho-toluidine The metabolite oxidizes Hemoglobin to Methemoglobin, resulting in Methemoglobinemia (doses > 600 mg can cause symptoms)

Treatment of Prilocaine induced methemoglobinemia?

Methylene Blue 1 to 2 mg/kg IV over 5 mins (initial dose) - dont exceed 7-8mg/kg

Procaine Metabolite:

Procaine Metabolite: **PABA** (ester anesthetics), excreted unchanged in the urine

What makes Benzocaine unique?

Weak acid instead of a weak base, like most LA. pKa = 3.5

Ester or amide determination is based upon which portion of the molecular structure?

Intermediate chain

What are the ester and amide local anesthetics?

Amides (have 2 i's)

What adjuvant medications prolong the duration of local anesthetics?

* Dexmedetomidine * Magnesium * Clonidine * Ketamine * Dexamethasone

Compute 1:10,000 Epi to mcg/mL

1,000,000/ 10,000 = 100 **100 mcg/mL**

Compute 1:1,000 Epi to mcg/mL

1,000,000/ 1000 = 1000 **1000 mcg/mL** *This is the epinephrine that we find in our crash carts.*

0.25% concentration is how many mg/mL

2.5 mg/mL

1% concentration is how many mg/mL?

10 mg/mL

2% concentration is how many mg/mL?

20 mg/mL *2% lidocaine is the most common concentration used in the OR*

Lidocaine Recommended Max Single Dose: Lidocaine Recommended Max Single Dose with/Epi Lidocaine Recommended Max Single Dose for Spinal

300 mg 500 mg w/ Epi 100 mg

Bupivacaine Recommended Max Single Dose Bupivacaine Recommended Max Single Dose with/Epi Bupivacaine Recommended Max Single Dose for Spinal

175 mg 225 mg w/ Epi 20 mg

Which anesthetic is great with surface anesthesia?

Lidocaine (2-4%)

What is an LTA?

* Lidocaine tracheal anesthesia * Localized tracheal anesthesia

Order of blockade during Peripheral Nerve Block?

The proximal area (site of LA administration) is affected first and then distal.

When the peripheral nerve block is wearing off, what comes back first? Proximal or Distal?

Proximal comes back first & then distal.

What is a Region Bier Block?

Bier Block IV injection of LA into an extremity isolated from the rest of the systemic circulation with a tourniquet. Sensation and muscle tone dependent on tourniquet

What is the sequence of blockades for a segmental block in Neuraxial Anesthesia? What nerves are involved?

1. SNS (Myelinated preganglionic B fibers) 2. Sensory (Myelinated A, B fibers, unmyelinated C fibers) 3. Motor (Myelinated A-δ and unmyelinated C fibers)

For SAB, the _______ effect is 2 spinal segments cephalad of the sensory block. For SAB, the _______ effect is 2 spinal segments below the sensory block.

SNS Motor

What dermatomes correspond with our cardiac accelerator?

T1 to T4

SAB Dose: 5 ft = ____ mL of 0.75% Bupivacaine Add ____ mL for every inch above 5 ft

1 mL 0.1 mL *For someone who is 5'5", you will give 1.5 mL of bupivacaine for a SAB.*

What is the difference between SAB and epidural blocks?

No differential zone of SNS, sensory, and motor blockade for epidurals

What makes up the tumescent solution?

* Diluted Lidocaine (0.05% to 0.1%) * Epinephrine 1:100,000

Highly diluted Lidocaine with Epi Tumescent dose (mg/kg).

35 to 55 mg/kg

What is the theory with the Tissue Buffering System?

1 gram of SQ tissue can absorb up to 1 mg of Lidocaine

Which class of local anesthetic is more prone to an allergic reaction?

Esters d/t to the PABA metabolite

What two factors predispose our OB population to LA toxicity? A. ↓ Plasma Esterase B. ↓ Plasma Proteins C. ↑ Plasma Esterase D. ↑ Plasma Proteins

A, B

What is the MOA of Intralipids?

Creates lipid compartment, provides for fat for myocardial metabolism, and encapsulates LA

Intralipid Bolus Dose: Infusion Dose: 1st 30 minutes:

Intralipid Bolus Dose: 1.5 mL/kg of 20% lipid emulsion Infusion Dose: 0.25/mL/kg/min for at least 10 mins 1st 30 minutes: 10 mL/kg MAX

What is Methemoglobinemia? Methemoglobinemia can be caused by what LA?

Potentially life-threatening complication d/t ↓ O2 carry capacity (metHb > 15%) Can be caused by **Prilocaine and Benzocaine**

What is the treatment for Methemoglobinemia? How fast can this reversal take place?

Methylene Blue: 1 mg/kg over 5 mins (max 7 to 8 mg/kg) Fe3+ (Ferric) can be reduced to Fe2+ (Ferrous) within **20 to 60 minutes.**

Cocaine-Associated Chest Pain Flow Chart. *Another one to memorize.*

Addition of epinephrine can do what to the systemic absorption of LA?

Decrease systemic absorption by 1/3

How will β blockers affect the cardiac foci action potential? What does this lead to?

* Prolong Phase 4 * ↓ dysrhythmias during ischemia and reperfusion (less excitable during the refractory period)

What is SCIP? Describe the protocol and its goals.

- Surgical Care Improvement Protocol - β-blockers must be given within 24 hrs of surgery for patients at risk for cardiac ischemia and ones already on β-blocker therapy.

What were the three β1 selective agents discussed in lecture?

- Atenolol - Metoprolol - Esmolol

What non-selective β-blocker has active metabolites and is generally shitty for anesthesia?

Propanolol | Propanolol is the prototypical BB

Differentiate the clearance mechanisms of metoprolol, atenolol, and esmolol.

- Metoprolol = Hepatic - Atenolol = Renal - Esmolol = Plasma cholinesterases

What drug is the **most selective** β1 antagonist?

Atenolol

What two scenarios were given in class for a β1 indication over a non-selective β blocker?

- DM: β2 can cause hypoglycemia by insulin potentiation - Airway: β2 potentiates bronchospasm

Is phenylephrine primarily a venoconstrictor or an arterioconstrictor?

Venous constriction > arterial constriction

What is the ratio of β to α blockade for Labetalol?

7:1

Which drug is an indirect acting sympathomimetic? MOA?

Ephedrine Causes release of NE from postganglionic SNS nerves

Which SNS agonist can be given IM? Why would this be done?

- Ephedrine IM 50mg - Long lasting increase in BP for OB patients who are recieving a spinal anesthetic (C section)

What is the preferred sympathomimetic for parturient patients? Why?

Ephedrine (It doesn't effect uterine blood flow)

What drug would be utilized for catecholamine-resistant hypotension?

Vasopressin

What drug would be used for ACE-Inhibitor induced resistant hypotension?

Vasopressin *Can occur with both ACEi and ARBs*.

What does nitroprusside vasodilate?

Arterial **and** venous vasculature

What vasodilator absolutely requires arterial line monitoring?

Nitroprusside, due to the immediate onset and transient duration

Where does nitroglycerin work?

- Large coronary arteries - Venous capacitance vessels

What is the firstline treatment for sphincter of Oddi spasm? What is second?

- Glucagon - Nitroglycerin

Which CCB has the greatest coronary artery dilation and least myocardial depression?

Nicardipine

Side effects of vasopressin?

- **Coronary artery vasoconstriction** - Stimulates GI smooth muscle - Decreased PLT counts (not clinically significant)

Your end stage COPD patient needs emergent BP control. Which medication could worsen his PaO2? NTG Nitroprusside Hydralazine Labetalol

Nitroprusside - release of CN causes O2 dissociation from Hb

What is the dose for Atenolol?

5mg q10min IV

What is the dose of metoprolol?

1mg q5min until 5mg is given

What two formulation of metoprolol are there?

- Metoprolol Tartate = multiple doses per day (shorter acting) - Metoprolol Succinate = One dose per day (longer acting)

What is the dose for esmolol?

20-30mg IV

What is the normal dosing of phenylephrine?

100mcg/mL

What is the dose for labetalol?

2.5 - 5mg IV; 10mg max

What is the IV push dose of epinephrine? How long does it last?

- 2-8mcg IVpush - 1-5 min

What is the infusion dose of epinephrine for β2 effects?

1-2 mcg/min

What is the infusion dose of epinephrine for β1 effects?

4 mcg/min

What is the infusion dose of epinephrine for predominantly α effects?

10-20 mcg/min

What is the dose of Nitroprusside?

**0.3** - 2 mcg/kg/min

What is the nitroglycerin dose?

5 - 10 mcg/min

What is the initial dose of hydralazine?

2.5mg

Ephedrine push dosage?

1-5 mg

Cumulative Final (Exam 4) Flashcards

(95 cards)