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Adv Anes. Pharm Spring 2024 > Exam 1/ Lecture 3: Benzodiazepines > Flashcards

Exam 1/ Lecture 3: Benzodiazepines Flashcards

1
Q

Lecture 1/24/24

What is the definition of a Sedative

A

a drug that induces calm or sleep

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2
Q

Lecture 1/24/24

What is the definiton of a Hypnotics?

A

a drug that induces hypnosis or sleep

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3
Q

Lecture 1/24/24

True or false: The definitions for sedative and hypnotics can be use interchangeablely.

A

True

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4
Q

Lecture 1/24/24

What are the 2 main similarities that sedatives and hypnotics have with anesthesia?

A
  • Inhibits thalamic and mid -brain RAS (Reticular Activating System)
  • Rerversibly inhibits CNS

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5
Q

Lecture 1/24/24

A patient that experieces active recall from a surgery (smell burning tissue, hear the saw, feel the pain) can develop what type of mental disorder?

A

PTSD

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6
Q

Lecture 1/24/24

Is unconsciousness described as a single state (yes/no) or a continuum?

A

Continuum

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7
Q

Lecture 1/24/24

What happened in 1937 regarding EEG monitoring?

A

EEG could be use to measure effects

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8
Q

Lecture 1/24/24

What happened in 1952 regarding EEG monitoring?

A

Depth of Anesthesia correlates with concentration of ether

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9
Q

Lecture 1/24/24

What are 2 observational findings that are related to the depth of sedation and reflected in the EEG activity?

A

Cereberal blood flow
Cerberal metabolic oxygen demands

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10
Q

Lecture 1/24/24

What can alter the cereberal blood flow and cerberal metabolic oxygen demands?

A

Anesthesia

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11
Q

Lecture 1/24/24

When placing leads on a patient for a electroencephalogram what does these abbreviation stand for:
* F =
* C =
* T =
* P =
* O =
* A =
​

A
  • F = Frontal
  • C = center
  • T = Temporal
  • P = Parietal
  • O = Occipital
  • A = Auditory

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12
Q

Lecture 1/24/24/

When placing leads on a patient for a elctroencephalogram what letter/lead can the CRNA use as a reference point?

A

Z

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13
Q

Lecture 1/24/24

What side were the odd and even number EEG leads placed on the patient head?

A

Odd - Left
Even -Right

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14
Q

Lecture 1/24/24

In 1996, what type of technology was created?

A

Bispectral Analysis (BIS)

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15
Q

Lecture 1/24/24

What are the 3 combination of anesthesia drugs that were used to test the bisepectral analysis (BIS)

A
  • isoflurane/oxygen
  • propofol/nitrous
  • propofol/alfentanil

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16
Q

Lecture 1/24/24

After removing the high and low frequency artifact on a BIS, what did the company develop that assessed the consciousness of the patient?

A
  • Mathematical algorithm based on the pattern, time, frequency, and amplitude

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17
Q

Lecture 1/24/24

What type of drugs cause the BIS to change in correlation to the patient movement?

A

Hypnotic drugs

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18
Q

Lecture 1/24/24

Less correlation is seen between the BIS reading and patient movement when a narcotic is administered at a ________ dose

A

High

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19
Q

Lecture 1/24/24

True or False: A patient with a BIS of 23 is conscious

A

False, No patient with BIS < 58 was conscious

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20
Q

Lecture 1/24/24

What level of the BIS would determine that a patient had a less than 5% chance of returning to consciousness within 50 seconds?

A

BIS <65

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21
Q

Lecture 1/24/24

What are 3 brands of BIS monitoring device today?

A

PSA (Patient State Index)
Narcotrend
GE Entropy

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22
Q

Lecture 1/24/24

What are the abbreviation and mean to these 4 abbreviation on BIS?
* SQI
* EMG
* EEG
* SR

A
  • SQI (Signal quality index) – the quality of the signal – good or bad signal
  • EMG (Electromyography) – reflects muscle stimulation caused by increased muscle tone or movement
  • EEG (Electroencephalogram) – individual brain signals compressed into one signal
  • SR (suppression ratio) - tells you in the last 30 sec - 60 secs how long the BIS remain at 0

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23
Q

Lecture 1/24/24

What 4 medication class examples that will cause a depression in the BIS number?

A
  • Hypnotics
  • Volatiles
  • NMBD
  • Opioids

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24
Q

1/24/24

What 2 examples of mediction that would cause an increase in the BIS

A
  • Ketamine
  • epinephrine

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25
# Lecture 1/24/24 True or False: Beta blockers will cause a depression in the BIS
True ## Footnote Slide 9
26
# Lecture 1/24/24 What is the range per company that BIS number should display to reflect that the patient is adequately sedated?
40 - 60 ## Footnote Slide 9
27
# Lecture 1/24/24 A patient BIS trend lower than 40 could be a correlation of what depth of sedation?
deep sedation ## Footnote Slide 9
28
# Lecture 1/24/24 A patient BIS trend higher than 60 could be a correlation to what depth of sedation?
Mininal sedation ## Footnote Slide 9
29
# Lecture 1/24/24 What are the 5 pharmacologic effects of benzodiazepines?
* anxioltics * sedation * anterograde amnesia * anticonvulsants action * Spinal -Cord medicated skeletal muscle relaxation ## Footnote Slide 11
30
# Lecture 1/24/24 What is the difference between anterograde and retrograde amnesia?
Retrograde amnesia is when you can't recall memories from your past. Anterograde amnesia is when you can't form new memories but can still remember things from before you developed this amnesia ## Footnote Slide 11
31
# Lecture 1/24/24 Benzodiazepines cause what type of amnesia to patients?
Anterograde amnesia ## Footnote Slide 11
32
# Lecture 1/24/24 Which type of amnesia last longer than the sedative effects?
Anterograde Amnesia ## Footnote Slide 11
33
# Lecture 1/24/24 What type of benzodiaepine was given via rectum as an anticonvulsant and can be use as a skeletal muscle relaxant?
Valium ## Footnote Slide 11
34
# Lecture 1/24/24 Benzodiazepines replace which class of drug?
Barbiturates ## Footnote Slide 12
35
# 1/24/24 what are organ system effects: Pulmonary of Midazolam/Versed
**Dose-dependent decreases in ventilation** -Decreases hypoxic drive -depression with COPD -Transient apnea if rapid IV esp. with opioid **Depresses swallowing reflex** **Decreases upper airway activity** ## Footnote Slide 28
36
# Lecture 1/24/24 Which specfic benzodiazepine does the pharmacologic works the best on?
Versed ## Footnote Slide 13
37
# 1/24/24 what are organ system effects: Cardiovascular of Midazolam/Versed
**Dose dependent increased HR, decreased BP** **Cardiac output unchanged** SVR decreased Helpful in pts with CHF??? - yes Enhanced hypotension with hypovolemia Does NOT inhibit BP/HR response to intubation Offsets hypotension noted above? ## Footnote slide 29
38
# Lecture 1/24/24/ What are the 4 main comparison stated in class regarding comparing the benzodiaepines to each other?
* Structurally similar * Specific pharmacologic antagonist ??? * Midazolam most commonly used in perioperative period * Diazepam / lorazepam has much greater ½ time than midazolam and more attractive for sedation postop ## Footnote Silde 13
39
# Lecture 1/24/24 Why do they CRNA use less ativan/ lorazepam now then in the past for post -op sedation management?
Due to the developement of precedex ## Footnote Slide 13
40
# 1/24/24 what is the Dosing for Sedation with Midazolam/Versed?
Preop/intraop sedation/anxiolysis 0.25-0.5 mg/kg oral (children) Peak 20-30 minutes 1-5 mg IV (adults) Peaks 5 minutes Elderly require decreased doses…..Greater CNS sensitivity ## Footnote slide 30
41
# 1/24/24
Midazolam Safety in Children: Preop : po 30 minutes before induction ## Footnote slide 31
42
# 1/24/24 what is the Dosing for Induction with Midazolam/Versed?
Dose: 0.1-0.2 mg/kg IV over 30-60 seconds Facilitated by preceding dose of opioid 1-3 minutes Fentanyl 50-100 mcq ## Footnote slide 32
43
# 1/24/24 Midazolam/Versed Dosing: Maintenance
Maintenance Uncommon -Can be used to supplement opioids, propofol, and volatiles -Decreases requirements for volatiles -Dose dependent manner Rarely associated with N/V or emergence excitement ## Footnote slide 33
44
# 1/24/24 Midazolam/Versed Postoperatvie Sedation
Dose: 1-7 mg/hr IV Markedly delayed awakening Active metabolites accumulate Clearance depends on hepatic metabolism not redistribution Society of Critical Care Medicine sedation guidelines 2-3 days Immune/T cell effects (versed has negative effects on) Unclear clinical significance ## Footnote slide 34
45
# 1/24/24 Diazepam/Valium is...
Highly lipid soluble More prolonged duration of action than midazolam Rarely used in anesthesia Midazolam so beneficial ## Footnote slide 35
46
# 1/24/24 Diazepam/Valium Preparation
Dissolved in organic solvents Insoluble in water Propylene glycol…pain on injection; glycol toxicity Soybean formulation…less painful ## Footnote slide 36
47
# 1/24/24 Diazepam/Valium Pharmacokinetics
Onset 1-5 minutes E ½ time 20-40 hours….extensively protein bound Similar Vd to midazolam d/t lipid solubility (larger…women vs men) Effects prolonged Hepatic failure/cirrhosis Age Dissociates from GABAa faster than lorazepam Shorter duration of action….longer elimination ½ time ## Footnote slide 37
48
# 1/24/24 Diazepam/Valium Metabolism
Cytochrome CYP3A pathway Active metabolites -Desmethyldiazepam* (48-96 hours) and oxazepam -Nearly as potent as diazepam -Return of drowsiness 6-8 hours Drug interactions similar to Midazolam ## Footnote slide 38
49
# 1/24/24 what are the organ system effects: CNS of Diazepam/Valium?
Similar to other BZD’s r/t CMRO2 and CBF Potent anticonvulsant -0.1 mg/kg IV -Abolishes DT’s, status epilepticus, lidocaine toxicity related seizures -Longer acting antiepileptic drug also administered (fosphenytoin…cerebyx) Can produce isoelectric EEG ## Footnote Slide 39
50
# 1/24/24 what are organ system effects: Pulmonary of Diazepam/Valium?
Minimal effects of ventilation Slight decrease in Vt After 0.2mg/kg IV increases in PaCO2 Exaggerated with opioids, alcohol, COPD Ventilatory depressant effects reversed by surgical stimulation ## Footnote slide 40
51
# 1/24/24 What are organ system effects: Cardiovascular of Diazepam/Valium
Minimal decreases in BP, CO and SVR *even with induction doses was great for cardiac surgery induction BP changes that do occur….. Additive with opioid Unchanged with addition of nitrous (unlike opioid/nitrous) Prevents recall ## Footnote slide 41
52
What is the Cardiovascular effect of Diazepam (Valium)?
did this study looking at an awake patient versus when they gave Valium versus one that had Valium and Nitrous: * Systolic pretty much unchanged * Diastolic pretty much unchanged * heart rate pretty much unchanged * Pulmonary artery pressures pretty much unchanged. So again, really solid, really safe. ## Footnote Slide 42
53
What is the Neuromuscular effect of Diazepam (Valium)?
* Decreases tonic effect on spinal neuron - skeletal muscle tone decreased - Develop tolerance to skeletal muscle relaxant effects * No action at neuromuscular junction - will need Vec, Roc, or Sux ## Footnote slide 43
54
What is the dosing for Diazepam (Valium)?
Induction: **0.5-1.0 mg/kg** IV Decrease dose by 25-50%: * Elderly * Liver disease * Presence of opioids ## Footnote slide 44
55
What is the MOA of Lorazepam (Ativan)
* Resembles oxazepam (Serax) * More potent sedative and amnestic compared to Midazolam and Diazepam ## Footnote slide 45
56
What is the preparation and onset of action of Lorazepam (Ativan)?
Preparation: **Insoluble in water and requires solvent (Polyethylene Glycol)** Onset of action: * slower than Midazolam or Diazepam * slower entrance to CNS (due to lower lipid solubility) * slower metabolic clearance Used for post-op sedative ## Footnote slide 46
57
What is the Peak Effect and IV dose of Lorazempam (Ativan)?
20-30 minutes with 1-4 mg IV dose ## Footnote Slide 47 and Slide 49
58
How is Lorazepam (Ativan) metabolise?
* conjugaged to **inactive metabolites** * not entirely dependent on hepatic enzymes -less affected by hepatic function, age, drugs -not as affected by blood flow ## Footnote slide 47
59
What is the Half-time of Lorazepam (Ativan)?
E ½ time **14 hours** * Slower than midazolam * Glucuronidation slower than oxidative hydroxylation ## Footnote slide 47
60
What is the organ system effects of Lorazepam (Ativan)?
* similar CNS effects * Heart effects * Pulmonary effects to other Benzodiazepines ## Footnote slide 48
61
# [](http://) What is the MOA of Flumazenil (Romazicon)?
1,4 imidazobenzodiazepine derivative * **Competitive antagonist**: high affinity for BZD receptor * **Prevents/reverses all agonist activity of BZD**
62
What is the metabolism of Flumazenil (Romazicon)?
It metabolizes to the patient's **microsomal enyzmes and inactive metabolites**
63
What is the dose of Flumazenil (Romazicon)?
**0.2 mg IV **and titrated to consciousness - **Repeated 0.1mg q 1 minute to 1 mg total** *Reversal within 2 minutes* **0.3-0.6 mg** to reverse sedation **0.5-1.0 mg **to abolish therapeutic dose *Unconscious/overdose AND 0.5-1mg without change means it is caused by other intoxicants* ## Footnote Slide 52
64
What is the duration of Flumazenil (Romazincon)?
**30-60 minutes** Supplemental doses vs continuous infusion (0.1-0.4 mg/hr)
65
What is the side effects and contraindication of Flumazenil (Romazincon)?
*Side effects:* **NONE** *Contraindication*: **patients on Benzodiazepine antiseizure drugs** (we can precipitate acute withdrawal seizure)
66
Which GABA receptor is primarily associated with the CNS?
GABA alpha-2
67
Which is the most abundant GABA receptor?
GABA alpha-1
68
Which 4 common drugs bind to GABA-A receptor?
Barbiturates, Etomidate, Propofol, Alcohol
69
After the administration of Benzodiazepines there will a _______ in alpha activity
Decrease
70
The following would have a synergistic effect would occur between Benzodiazepines:
* Alcohol * Injected anesthetics * Inhaled Anesthetics * Opioids * Alpha-2 Agonists (Ex: Precedex, Clonidine)
71
Benzodiazepines cause a conformational change in plates by _____ platelet aggregating factor
- Inhibit
72
What is type of chemical structure stabilizes Midazolam (Versed)?
Imidazole Ring
73
Midazolam (Versed) is ______ times as potent as Diazepam (Valium
2-3
74
Midazolam becomes water soluble in what state?
When it is protonated at a pH <3.5
75
What is the onset time of Midazolam (Versed)?
1-2 Minutes (IV administration)
76
What is the E ½ of Midazolam (Versed)?
2 hours
77
What is the Volume Distribution of Midazolam (Versed)
Vd = 1-1.5 L/Kg
78
The E ½ of Midazolam is doubled in what population?
Elderly Patients
79
What effects does a high dose of Midazolam have on CMRO2 (Cerebral Metabolic Rate of Oxygen) and CBF (Cerebral Blood Flow)?
Decreases both CMRO2 and CBF
80
Is Midazolam (Versed) a potent anticonvulsant?
Yes, even in status epilepticus

Adv Anes. Pharm Spring 2024 (7 decks)

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