Exam 2 Material Flashcards
(554 cards)
1
Q
What enzyme metabolizes phenylephrine?
A
MAO
Monoamine oxidases
2
Q
Which adrenergic agonist is NOT arrhythmogenic?
A
Phenylephrine
3
Q
Which selective alpha 2 agonist is more highly protein bound?
A
Dexmedetomidine
4
Q
Name the endogenous sympathomimetics
A
Norepinephrine
Epinephrine
Dopamine
5
Q
Define chronotropy
A
Affects heart rate
6
Q
What receptors does clonidine work on?
A
-alpha 1 and alpha 2 adrenergic receptors
-acts as an anti hypertensive
7
Q
Why is clonidine use in PNB?
A
Extends life if PNB
8
Q
What receptor does dexmetomidine work on?
A
Central acting alpha 2
9
Q
What is dexmetomidine used for intra-operatively?
A
Sedative
Proanesthetic
10
Q
Dexmetomidine blunts central ____ response
A
Sympathetic
11
Q
What 5 things does dexmetomidine reduce in patient intraop
A
-opioid muscle rigidity
-reduces post op shivering
-little respiratory depression
-hemodynamically stabilizing effect
-reduced opioid requirements
12
Q
Dexmetomidine can cause a _____ in HR
A
Decrease
Alpha 2 may lead to hypotension when combined with other anesthetics
13
Q
What is a sympathomimetic
A
Stimulates adrenergic receptors
14
Q
what is the protype drug for sympathomimetics
A
epinephrine
15
Q
what receptor relates to vasculature
A
alpha 1
16
Q
what receptor relates to heart rate
A
beta 1
17
Q
what receptor relates to bronchiole smooth muscle
A
beta 2
18
Q
what drug is an agonist for all adrenergic receptors?
A
epinephrine
19
Q
what does alpha 1 stimulation do
A
-arteriolar vasoconstriction
-pulmonary artery vasoconstriction
20
Q
What does beta 1 stimulation do
A
-increase HR
-increase myocardial contractility
-increased CO
21
Q
what does beta 2 stimulation do
A
-vasodilation in airway smooth muscle
-vasodilation of skeletal muscle
-increase cAMP
22
Q
what is mydriasis
A
contraction of iris= dilation
23
Q
what are the metabolic effects of epi
A
hypokalemia
hyperglycemia
24
Q
norepinephrine has ___ alpha 1 than epi
A
greater
25
norepinephrine has ___ B2
NO
26
when compared to epi, norepi has ___ effect on SVR, systolic/diastolic BP, and MAP.
This is due to its affect on the ___ receptor
greater
alpha 1
27
what is the first line vasopressor for septic shock
norepinephrine
28
how much metabolic effect does norepi have
limited (not as much K or blood sugar effect)
29
what systems does dopamine help regulate
-cardiac
-vascular
-endocrine
-central nervous system
-peripheral nervous system
30
what receptors does dopamine affect
D1 D2 alpha and beta
31
what are the effects of D1 stimulation
-vasodilation of renal, mesenteric, coronary and cerebral
32
what are effects of D2 stimulation
inhibits norepi release
33
what is the reward mechanism in the brain
dopamine
34
what receptors are activated at dopamine rate 0.5-3 mcg/kg/min? What is its effect?
D1 and D2
vasodilation, decreased arterial BP, increased renal and splanchnic blood flow
35
what receptors are activated at dopamine rate 3-10mcg/kg/min
B1
alpha 1 increase
36
what does an increase in dopamine dose put a patient at risk for
arrhythmias
37
what is the half life of dopamine
1-2 min
38
what 6 things does dopamine increase
-myocardial contractility
-renal blood flow
-GFR
-Na excretion
-Urine output
-intraocular pressure
39
what are two synthetic catecholamines
isoproterenol
dobutamine
40
what is isoproterenol used for
heart blocks
B1 B2 agonist
41
what are the effects of isoproterenol
-increased HR
-increased contractility
-decreased SVR through skeletal muscle vasodilation
42
what is dobutamine?
-synthetic catecholamine
-racemic mixture of isoproterenol
43
what receptor is dobutamine specific for?
B1, weak B2 effects
44
does dobutamine have alpha effects
yes at high doses
45
does isoproterenol have alpha effects?
NO
46
what is dobutamine used for?
heart failure
weaning from bypass
47
what are the effects of dobutamine?
increased contractility
decreased afterload
48
what are two synthetic noncatecholamines
ephedrine
phenylephrine
49
what is the indirect acting sympathomimetic
ephedrine- must go through metabolism
50
what receptor does ephedrine work on
alpha and beta
51
which synthetic noncatecholamine mimics epi
ephedrine
52
what is benefit of ephedrine over epi
less intensity
lasts longer
53
what happens when you keep giving ephedrine
tachyphylaxis, effect diminishes have to give higher doses
catecholamine depletion at the synapse
54
which synthetic noncatecholamine mimics norepi
phenylephrine
55
what receptor does phenylephrine act on
alpha 1
56
what kind of vessel does phenylephrine constrict
venous and arterial
57
what is a reflex effect of phenylephrine
baroreceptors reflex vagal from elevated BP, bradycardia
58
what is the effect of selective B2 adrenergic agonist
relax bronchioles and uterine smooth muscle
59
what is the protype drug for beta 2 agonist
albuterol
60
what are the routes of admin for B2 agonists
inhaled most common
oral and subq
61
what happens when you put inhaler through ETT
decrease dose by 50-70%
62
what is calcium used as in anesthesia
inotrope
63
when is ionized Ca used to treat cardiac depression
-volatile anesthetics
-citrate infused blood products
-post bypass
64
what has effect on heart: ionized Ca or total plasma calcium
ionized
65
acidosis ___ ionized Ca
increases
66
alkalosis ___ ionized Ca
decreases
67
infusion dose for isoproterenol
0.015-0.15mcg/kg/min
68
how is isoproterenol metabolized
rapidly by COMT
69
what is infusion dose of dobutamine?
2-20mcg/kg/min
70
IV dose of ephedrine
5-25mg
IM dose up to 50mg
71
ephedrine is a ___ inotrope and ____ O2 demand with CAD
positive, increase
72
what potent alpha agonist is the chemical precursor of epinephrine?
norepinephrine
73
an FDA Black Box warning is attached to what B2 selective agents?
salmeterol and formoterol
74
which adrenergic receptor agonist is metabolized by the liver?
ephedrine
75
which synthetic catecholamine is derived from dopamine?
isoproterenol
76
what is the precursor of norepinephrine
dopamine
77
How does labetalol possess intrinsic sympathomimetic activity (ISA)?
Partial stimulation (agonist) action at the beta adrenergic receptor while blocking endogenous catecholamines from binding to the beta receptor
Less potent than catecholamines and other beta agonists
78
Concerns with beta antagonists
-brandy arrhythmias
-obtunding the cardiovascular response to hypovolemia
-progressive heart block
-HF
-bronchoconstriction
Abrupt d/c can cause rebound HTN and tachycardia
79
What can happen to the selectivity of a selective beta blocker if dose increases
The degree of selectivity is diminished
80
What is the ratio of beta to alpha block for labetalol
7 (beta) : 1 (alpha)
81
What receptors does labetalol effect
Alpha 1
Beta 1 and beta 2
Non selective beta antagonist
82
Half life and metabolism of labetalol
Half life: 6 hrs
Metabolized in liver, eliminated by kidneys
83
Propranolol’s use as an anti-dysrhythmic is best related to its:
Membrane stabilizing ability (MSA)
84
Administration if a B2 receptor antagonist to a patient with COPD may trigger?
Bronchoconstriction
85
Which beta blocker has intrinsic sympathetic activity (ISA)
Labetalol
86
Which beta receptor antagonist undergoes renal metabolism
Atenolol
87
What’s the most common side effect of prazosin
Orthostatic hypotension
88
Which beta blocker is metabolized by non specific esterases?
Esmolol
89
What substance is a an agonist of acetylcholine
Nicotine
Nicotine is a cholinomimetic
90
What effect does diltiazem have on the AV node?
Negative dromotropic
91
Define dromotrope
-A dromotropic agent affects the conduction speed (the magnitude of delay) in the AV node of the heart
-influences the rate of electrical impulse propagation in the heart
Negative- prolongs AV node conduction
Positive- shortens AV node conduction
92
CCBs produce greater relaxation of ___ vs ____
Arterial than venous smooth muscle
Many CCBs induce coronary artery vasodilation and inhibit coronary artery vasospasm
93
Verapamil and diltiazem are class ____ antiarrhythmics that______
Class 4
That depress electrical impulses in the SA and AV nodes
94
Effects of CCBs on O2 supply and demand
Demand:
-decrease after load
-decrease preload
- decrease contractility
-can decrease or increase Hr
Supply:
- increases diastolic perfusion
-decreases vasoconstriction
-decreases arterial spasms
95
How do CCBs work?
Block the biochemical pores preventing the movement of ions across the membrane
Targets L form ca channels
96
What are CCBs used to treat
HTN
Arrhythmias
Peripheral vascular disease
Cerebral vasospam
Angina
97
Rank the CCBs (highest to lowest) ability to impair contractility
Verapamil
Nifedipine (Procardia)
Diltiazem
Nicardipine (Cardene)
Example: In a patient with decreased contractility you would choose Diltiazem over verapamil
98
Which CCB better control HR?
Verapamil and Diltiazem
99
Which CCB is the only one proven to reduce morbidity and mortality from cerebral vasospasm?
Nimodipine
100
CCBs preserve ____ while reducing ____
Preserve preload
Reduce LV after load
101
Which type of calcium channel do CCBs target
L type
102
Which CCBis often prescribed for Raynaud’s disease?
Nifedipine
103
What drug is a nitric oxide donor with great effect on venules than arterioles
Nitroglycerin
104
Which specific PDE inhibitors prevent platelet aggregation
PDE 3 inhibitors
105
Which specific receptor (subtype) mediates cardiovascular effects of vasopressin?
V1 receptor
106
Which PDE inhibitor is useful in inflammatory states?
PDE 4 inhibitors
107
Which PDE inhibitor selectively increases cGMP
PDE 5 inhibitors
108
The dry cough associated with an ACE-inhibitor is most likely due to
Accumulation of bradykinin
109
What are the best agents to augment the heart rate in a patient after heart transplant?
Epinephrine
Isoproterenol
110
what messenger does beta 1 stimulate
cAMP
111
what is an alpha 2 agonist
sympatholytic
112
what is the MOA of alpha 2 agonists
competitively bind to alpha 2 receptors inhibiting the neurotransmitter NE release
113
what can happen with ending of alpha 2 agonists
rebound HTN and tachycardia from increase in sympathetic flow
114
what are examples of alpha 2 agonists
clonidine and dexmetomidine (precedex)
115
where does dexmetomidine act
locus ceruleus
116
what are the benefits of dexmetomidine
blunts sympathetic response
airway reflexes remain unchanged
minimal resp depression
reduction of opioid requirements
use in awake intubations
117
what are side effects of dexmetomidine
bradycardia and hypotension
118
what can happen with large doses of dexemetodine
transient hypertension due to the crossover stimulation of alpha 1
119
what are withdrawal symptoms of dexmetomidine
HTN
tachycardia
anxiety
120
what is dosing for dexmetomidine
IV 0.1-1.5 mcg/kg/min
loading dose 1mcg/kg
121
where are alpha 2 receptors located
pre-synaptic neurons
122
what is the MOA of alpha antagonists
inhibit the effects of catecholamines and sympathomimetics on the heart and vasculature
123
what are effects of alpha antagonists
decreased BP
decreased BPH effects
124
what are side effects of non selective alpha antagonists
reflex tachycardia (baroreceptor mediated from vasodilation)
125
what medication do we use for pheochromocytoma
phenoxybenzamine (labetalol, prazosin)
126
what are examples of non selective alpha antagonists
phentolamine
phenoxybenzamine
127
what is the onset and half life of phenoxybenzamine
onset 1 hr
half life 24 hrs (due to covalent bond)
128
what happens with hypotensive patients and non selective alpha antagonists
vasodilation and more hypotension
129
what are examples of selective alpha 1 adrenergic antagonists
terazosin
prazosin
tamsulosin
130
what is the alpha 2 selective antagonist
yohimbine
used for some htn
131
what are uses of selective alpha antagonists
BPH and HTN
132
what does happens with beta 1 stimulation
increased contraction
increased HR
increased conduction rate through AV node
133
what are the effects of beta blockers
decreased HR
decreased AV conduction
decreased contractility
decreased myocardial oxygen consumption
relaxation of the heart
increased airway resistance
134
why are beta blockers used in CABG patients
decrease incidence of afib
135
what medication do you NOT use in asthma patients
non selective beta blockers (like propanolol)
136
what beta blocker is highly protein bound
propanolol
137
what are examples of selective beta blockers
metoprolol
atenolol
esmolol
138
what receptors are selective beta blockers selective for
beta 1
139
what kind of beta blockers are better with airway diseases or asthma
cardioselective
140
what is the risk of non selective beta blockers
more side effects
risk of bronchospasm
141
should patients stop beta blockers in periop period
no, continue to avoid rebound effect
142
what kind of beta blocker is best for diabetic patients
atenolol
143
what are anesthesia considerations for Beta antagonists
myocardial depression
airway resistance
changes in metabolism
increased extracellular potassium
anesthesia interactions
nervous system effects
fetal bradycardia
hypotension
144
what are the side effects of beta blockers
MYOCARDIAL DEPRESSION
bradycardia
hypotension
cardiogenic shock
145
how do you treat beta antagonist overdose
glucagon and maybe calcium chloride
146
what are the side effects of beta blockers
airway resistance (more likely with propanolol)
masks symptoms of hypoglycemia (tachy, palpitations, tremors anxiety)
increased extracellular K (nonselective)
147
what kind of beta blockers are not recommended in diabetic patients
non selective (propanolol)
148
how does propanolol effect local anesthetics
slows clearance of local amides
decreases pulmonary uptake of fentanyl (2-4x in circulation)
149
how does timolol interact with inhaled anesthetics
profound bradycardia
150
what beta blocker can cross the BBB and what are the effects
propanolol (lipid soluble)
causes lethargy and fatigue
151
what beta blockers can cross the placenta and what is the effect
propanolol and labetalol- cause hypotension and bradycardia
still the first line therapy for acute onset or emergent HTN in pregnancy
152
what receptors does labetalol work on
alpha 1 and non selective beta antagonist
153
what is the MOA of labetalol
alpha 1 blockade: lowers systemic BP by decreasing SVR
beta nonselective blockade: lowers reflex tachycardia by vasodilation
154
what are the clinical uses of labetalol
HTN emergencies
rebound HTN
pheochromocytoma
155
what are common side effects of labetalol
orthostatic hypotension
bronchospasm
CHF
bradycardia
heart block
156
what are uses of CCBs
HTN
cardiac arrhythmias
angina pectoris
157
what are the pharmacological effects of CCBs
decreases HR
decreases myocardial contractility
decreases SA node activity
decreases cardiac conduction through the AV node
decreases systemic BP
relaxes smooth muscle
vasodilation
158
what are two types of CCBs
dihydropyradines
non-dihydropyradines
159
what do dihydropyradines effect
vessels
160
what are examples of dihydropyradines
nifedipine
nicardipine
amlodapine
nimodipine
161
what do non dihydropyridines effect
heart
162
what are the divisions of non dihydropyridine CCBs
phenylalkylamines (verapamil)
benzothiazepines (diltiazem)
163
what vessels does nimodipine mostly work on
cerebral vessels
think arterial vasospasm
164
what vessels do nifedipine and nicardipine work on
arteriolar beds
165
what is the effect of nifedipine
coronary/peripheral arterial vasodilator
no effect on SA/AV
increases in HR from baroreceptors
angina pectoris
166
what are side effects of nifedipine
flushing, vertigo, head ache
may have: peripheral edema, hypotension, paresthesias, skeletal muscle weakness
167
what happens when you abruptly d/c nifedipine
coronary artery vasospasm
168
where does nimodipine work?
cerebral arteries
highly lipid soluble
169
what are uses for nimodipine
cerebral vasospams
cerebral protection after MI
170
what is contraindication for any BB or CCB
heart block
171
what does verapamil do
negative chronotropy on SA
depresses AV
negative inotrope
cardiac muscle vasodilates coronary arteries
172
what does verapamil treat
SVT
angina pectoris
essential HTN
hypertrophic cardiomyopathy
173
what are side effects of verapamil
HF
bradycardia
SA dysfunction
AV block
ventricular dysrhythmias
WPW syndrome
174
what does diltiazam do
blocks ca channels and Na-K pump
inhibits calcium calmodulin binding
175
what does diltiazem treat
SVT and HTN
176
what is a contraindication for CCBs
heart blocks
conduction abnormalities
177
can you continue CCBs through surgery
yes
178
how can you reverse CCB overdose
IV calcium or dopamine
179
how do CCBs affect NMB
increase effects
180
how do CCBs effect K levels
hyperkalemia
especially with K and verapamil
181
how do CCBs effect platelet function
Interfere with platelet functions
182
how do CCBs effect digoxin
increases the plasma concentration
183
how do CCBs effect H2 antagonists
cimetidine and ranitidine increase CCB plasma concentrations
184
name some other outcomes from CCBs
prevent ischemic reperfusion injury
decreased effect of nephrotoxic drugs/contrast media
increases renal blood flow and GFR
185
what is stage 1 HTN
130/80-139/89
186
what is stage 2 HTN
>=140 sys and >= 90 dias
187
what is the most common type of HTN
primary/essential HTN
188
what are causes of secondary HTN
OSA
renal disease
renal artery stenosis
pheochromocytomac
cushings
hyper/hypo thyroid
oral contraceptives
chronis NSAID use
antidepressants
ETOH
aortic coarctacion
189
what are risks of HTN
atherosclerosis
HF
stroke
renal disease
death
190
what are lifestyle changes for HTN
change diet
smoking cessation
weight loss
exercise
lower salt intake
medication
191
what is initial therapy for essential htn
thiazide diuretics then dihydropyridine CCB, ace or arb
192
should antihypertensive therapy be continued through surgery
YES
193
what are the adrenergic receptors
alpha 1 alpha 2 beta 1 beta 2
194
alpha 1 stimulation causes
vasoconstriction
increase in peripheral resistance
increase in BP
mydriasis
increase closure of bladder sphincters
NE>EPI
195
alpha 2 stimulation causes
inhibits norepi release
inhibits Ach release
inhibits insulin release
EPI>NE
196
beta 1 stimulation causes
increased HR
increased lipolysis
increased myocardial contractility
increased renin
EPI= NE
197
beta 2 stimulation causes
vasodilation
decreased peripheral resistance
bronchodilation
increased glycogenolysis (muscle and liver)
increased glucagon release
relaxes uterine smooth muscle
EPI>> NE
198
what are examples of nonselective BB
propanolol, carvedilol, labetalol
199
what is MOA of metoprolol
B1 blocker
200
what is MOA of labetalol
A1 B1 and B2 blocker
201
what is MOA of esmolol
B1 blocker
202
what is class of CCB is nicardipine
dihydropyridine CCB
203
what is mechanism of hydralazine
arteriolar dilator
204
what is mechanism of nitroprusside
NO donor
205
what is mechanism of nitroglycerin
NO donor
206
what receptor do selective BB attach to
B1
207
what is MOA of alpha 1 antagonists
lower BP by blocking alpha 1 receptors so they cant constrict
dilate venous and arterial vessels
208
what is the protype drug for alpha 1 blockers
prazosin
209
what are side effects of alpha 1 antagonists
vertigo
fluid retention
orthostatic hypotension
210
what type of drugs interfere with prazosin anti HTN effects
NSAIDS
211
if a pt is on alpha 1 antagonist what alpha agonist would you use?
epi
212
what anesthesia procedure can cause hypotension when pt is on alpha 1 antagonist
spinal/epidural
213
what receptor does clonidine work on
alpha 2 agonist
214
what are desired effects of clonidine
vasodilation
decreased BP
decreased HR
decreased CO
215
what are side effects of clonidine
sedation
dry mouth
skin rashes
impotence
orthostatic hypotension
216
how do you stop clonidine use
gradually decrease over 7 days
217
what can happen with abrupt d/c of alpha 2 antagonist
rebound HTN
218
advantage of using clonidine and dexmetomidine together
induced sedation
decreased anesthetic requirements
improved perioperative hemodynamics
219
what is the MOA ace inhibitors
decreased angiotensin 2 production leading to decreased vasoconstriction
220
how does angiotensin 2 produce vasoconstriction
leads to increased release of Ca from sarcoplastic reticulum to produce vasoconstriction
221
what is MOA of ARBs
block binding of angiotensin 2 to AT1 receptor blocking angiotensin 2 from causing vasoconstriction
222
what are side effects of ACE inhibitors/ ARBs
ACE:
cough
angioedema
BOTH:
congestion
rhinorrhea
allergy like symptoms
223
what is the only IV ACE inhibitor
enalaprilat
224
do you continue ace and arbs intraop
no
leads to hypotension, D/C 12-24 hours before surgery
225
what dietary constraints do you needs with CCBs
none, patients can have Na
226
what is MOA of CCBs
block Ca influx through L type Ca channels in vascular smooth muscle
227
what type of CCB is nifedipine
dihydropyridine
228
what type of CCB is nicardipine
dyhydropyridine
229
what do dihydropyridine CCBs mostly work on
vessels (vasodilate)
230
side effects of Dihydropyridines
reflex tachycardia
negative inotropy
hypoxemia due to V/Q mismatch (vasodilation)
231
what type of CCB is verapamil
non dihydropyridine
232
what type of CCB is diltiazem
non dihydropyridine
233
where do non dihydropyridines mostly work
heart, antiarrythmic
234
what are nondihydropyridine used for
negative chronotropy
negative inotropy
antiarrhythmic
235
what is the MOA of phosphodiesterase inhibitors
increase cGMP and cAMP which reduced intracellular Ca which causes smooth muscle relaxation (vasculature, lungs, penis, bowels)
236
what is effect of inhibition of PDE3
positive inotropy
237
what are examples of PDE3 inhibitors
amirinone
milrinone
238
what are common PDE5 inhibitors
sildenfil
tadalafil
vardenafil
239
what are side effects of PDE3 inhibitors
head ache
ventricular arrythmias
hypotension
240
what are side effects of PDE5 inhibitors
nasal congestion
dyspepsia (indigestion)
flushing
priapism
241
what are PDE5 inhibitors used for
ED
pulm HTN
242
what are PDE 3 inhibitors used for
MI
intermittent claudication
243
what are PDE4 inhibitors used for
asthma
COPD
inflammatory conditions
244
where does nitric oxide cause vasodilation
lungs
245
what is nitric oxide used to treat
VQ mismatch only approved in peds lung injury
off label:
pulm htn with R heart dysfunction
heart lung transplant
246
why do you d/c NO slowly
rebound pulm HTN
247
what is side effect of nitroprusside (SNP) or any nitric oxide
methemoglobin
cyanide toxicity
NO release
248
how does SNP effect heart, renal hepatic cerebral pulm and hematological
heart: decrease BP, tachycardia, increased contractility, increase CO
renal: decrease function
Hepatic: no changes
cerebral: increased cerebral blood flow, increased ICP
pulm: decreased PaO2
heme: inhibits platelet aggregation
249
what drug causes cyanide toxicity
SNP / nitroprusside
250
when do you expect cyanide toxicity in nitroprusside
increasing dose, pt no longer responsive to previous dose
PEDs have accelerated toxicity
251
signs and symptoms of cyanide toxicity
tachyphylaxis-needing to go up on gtt
metabolic acidosis
increase PvO2
altered mental status
seizures
252
treatment for cyanide toxicity
d/c nitroprusside
100% FiO2
-sodium bicarb for acidosis
sodium thiosulfate
hydroxycobalamin (B12a) (red discoloration of skin)
sodium nitrate for severe toxicity
253
where do nitrates work to cause vasodilation
large coronary arteries
arterial relaxation
254
examples of nitrates
nitroglycerin
255
MOA of nitrates
generate NO, stimulate cGMP, vasodilation
256
what do nitrates require to work
thio containing compounds
257
when do we use nitrates
suspected MI
volume overload HF
HTN
controlled hypotension
258
what does hydralazine do
direct arterial vasodilator
afterload reduction
259
side effects of hydralazine
SNS stimulation
increased HR and contractility
260
what type on patient is hydralazine not recommended in
myocardial ischemia
CAD
261
what condition is hydralazine often used for
pregnancy HTN
262
what is onset of hydralazine
delayed
263
what can long term use of hydralazine lead to
systemic autoimmune disease (lupus)
264
what messenger does beta 1 stimulate
cAMP
265
where are alpha 1 receptors located
blood vessels
bladder (urinary retention)
pupils (dilation)
ejaculation
266
what do alpha 2 receptors do
negative feedback for NOREPI release
267
Parasympathetic affects which nerves
Cranio sacral
Cranial nerves: 3 7 9 10
Pelvic splanchnic nerve
268
what are epi drip dosing and receptors it stimulates
1-4mcg/min stimulates B2
10-20 mcg/min stimulates both alpha and beta ; more alpha than beta
269
how does nifedipine affect SVR and heart rate?
decreases SVR and reflex increase in HR
270
when would you use sublingual nifedipine?
used to treat intraoperative myocardial ischemia when hemodynamics are normal
271
describe the actions of epinephrine on skeletal muscle blood flow
Beta 2 effects of epinephrine increase blood flow to skeletal muscles
272
what happens to CO and SVR with low dose epi? what receptors produce the effects
CO increases secondary to stimulation of cardiac Beta 1 receptors which increase HR and myocardial contractility
SVR decreases secondary to stimulation of vascular beta 2 receptors, most in skeletal muscle vasculature
273
what happens to systolic, diastolic, pulse pressure, and MAP with low dose epi?
sys increases due to B1 increase in CO
dias decreases due to B2 mediated vasodilation
pulse pressure increases
MAP generally increases, but could decrease or remain unchanged
**the change in MAP depends on how much sys increases and diastolic decreases**
274
at what concentration of epi will effects of bronchodilation predominate
lower doses
(0.25 to 0.50 mcg/min) primarily causes bronchodilation
275
at low dose epi (0.25 to 0.50 mcg/kg) theres bronchodilation, what physiological responses occur as the dose of epi increases
epi doses >0.5mcg/kg cause increase in inotropy, chronotropy, and vasoconstriction
as dose increases stroke volume may fall as SVR increases
significant tachycardia, dysrhythmias and myocardial ischemia may limit usefulness of epi
276
what two enzymes metabolize catecholamines in the body? what are these enzymes located and where are the enzymes specifically concentrated?
MOA and COMT
MOA concentrated in the mitochondria of presynaptic nerve terminal along with COMT found in the blood, liver and kidneys
COMT found in post synaptic nerves and in high concentration in the liver
277
by what mechanism does cocaine alter sympathetic function
cocaine blocks reuptake of norepinephrine
278
what is the drug of choice for treating the hypotensive cocaine addict? what drugs for be avoided and why?
direct acting agents are most effective
avoid indirect acting agents such as ephedrine
cocaine inhibits the reuptake of epinephrine and norepi thereby potentiating responses to exogenous/endogenous released catecholamines, result may be remarked pressor response.
279
Inotrope
Force of contraction
280
Chronotrope
Heart rate
281
Dromotrope
Conduction velocity through AV node
282
Give dopamine doses and the receptors that are activated at each
1-4 mcg/kg/min dopamine receptors
5-10mcg/kg/min beta receptors (elicits release of norepi via B1 stimulation)
11-20mcg/kg/min alpha receptors
283
Why is dopamine not used in gram negative sepsis?
Because sensitivity of beta receptors is diminished due to down regulation
284
How does dopamine affect aldosterone
Inhibits aldosterone causing increase in sodium excretion and urine output
285
What enzyme metabolizes dopamine
MAO and COMT
caution pts with MAOI can have prolonged effects of dopamine
286
How do antidepressants effect sympathomimetics
MAOI can prolong effects
Tricyclic can augment the effects
287
What is Isoproterenol mostly used for
Treatment of bradycardia with heart block
Torsades de pointes
Chronotropic support after heart transplant
288
What are three factors that limit the use of Isoproterenol
Excessive tachycardia
Induction of myocardial ischemia
Arrhythmias
289
Why is dobutamine used in cardiogenic and septic shock
Positive inotrope with lack of chronotropy and maintenance of normal BP (nahelhout 180)
290
Where is vasopressin stored and released from
Stored in Posterior pituitary gland
Released from neurons of the hypothalamus
291
What’s the function of vasopressin
Controls osmoregulation- release is stimulated by increased osmolality and hypovolemia
292
Vasopressin selectively dilates 3 things?
Renal afferent arterioles
Pulmonary arterioles
Cerebral arterioles
293
Why do we use phenylephrine over ephedrine in pregnant patients?
Ephedrine produces increases in fetal metabolic rate leading to fetal acidosis due to beta stimulation
294
What drug is used in pts with pheochromocytoma to decrease the response to endogenous catecholamines?
Phenoxybenzamine
Start 1-3 weeks before surgery
295
Phenylephrine stimulates what receptors? Describe the cardiovascular action of phenylephrine
Activates alpha 1 and alpha 2
Greater venoconstriction than arterial constriction
Elevates BP by increasing SVR and increased venous return with reflex decrease in Hr and CO
296
What is the important clinical response to blockade of the autonomic ganglia? What division of the ANS mediates this?
Hypotension secondary primarily to venodilation but also some arterial dilation
Response occurs because transmission of sympathetic impulses is blocked
297
Norepinephrine stimulates what adrenergic receptors?
Alpha 1 alpha 2 and beta 1 with little effect on beta 2
298
What adrenergic receptors are stimulated by epinephrine?
Alpha 1, 2 Beta 1,2
299
Which adrenergic receptors, alpha or beta, are most sensitive to epi?
Beta
Think low dose epi stimulates beta receptors
300
How does Epi increase Bp?
-venoconstriction and increased venous return
-arterial constriction and increased SVR
- increased myocardial contractility
301
What are the side effects of phenylephrine
-reflex bradycardia
-decreased CO
-increased myocardial oxygen requirements
302
What is the rationale for giving phenylephrine to the patient who becomes hypotension and shows sign of myocardial ischemia?
It will increase coronary perfusion by increasing arterial Bp
303
Ephedrine stimulates what adrenergic receptors? are the effects direct, indirect or both?
Ephedrine stimulates indirectly and directly alpha 1 and 2, beta 1, 2
It triggers the release of norepinephrine from nerve terminals producing indirect effects, also directly stimulates adrenergic receptors
304
Describe cardiovascular actions if ephedrine
Produces venoconstriction greater than arterial construction which leads to improved venous return and CO.
Beta stimulation increases Hr and CO
Alpha and beta effects result in modest and predictable increases in BP
Ephedrine is “weak” epi
305
What is the clinical use of ephedrine? What are side effects?
Used to treat hypotension (5-10mg IV)
Tachycardia and cardiac dysrhythmias possible
306
What is a proposed mechanism for the tachyphylaxis associated with the use of an indirect acting sympathomimetic?
It may develop because of depletion of norepinephrine from sympathetic post ganglionic nerve terminals
307
What receptors are stimulated by dobutamine?
Predominantly beta 1 but some beta 2 and alpha receptors
Increases contractility more than increase Hr
308
Dobutamine affects the cardiovascular system in what ways?
Increases CO by improving stroke volume with minimal increases in Hr and BP and only small decreases in SVR
309
Drugs that stimulate what receptors have both positive inotropic and positive chronotropic properties?
B1 stimulation have both positive inotropic and positive chronotropic
310
Isoproterenol stimulates what receptors and what are 3 cardiovascular actions of it?
Stimulates B1 and B2
Increases CO by enhancing HR and myocardial contractility (B1 effect)
Increases conduction through AV node (B1 effect)
Reduces SVR and after load by dilating skeletal muscle blood vessels (B2 effect)
311
What may be the most important clinical use of Isoproterenol
Used temporarily as a chemical pacemaker in complete heart block
312
What is the most frequent cause of death from digitalis toxicity
V fib
313
What herbs increase bleeding tendencies
Garlic
Ginger
Ginkgo biloba
Ginseng
314
Herbs that reduce MAC (have increased GABA effect)
Kava kava
Valerian
315
What are some complications of ephedra containing compounds?
-SNS effects
-Catecholamine depletion
-Increased risk of serotonin syndrome when given with MAOIs
316
what are side effects of isoproterenol
-increase myocardial O2 consumption
-may descrease myocardial O2 delivery due to decreased coronary artery blood flow
317
what is the most common uses of dopamine?
positive inotrope effect in pts with poor cardiac contractility
318
where in the CV system are B2 receptors predominantly located? what happens when these are stimulated?
-primarily found in the smooth muscle of the vasculature of skeletal muscles
-stimulating in vascular walls causes vasodilation
-SVR decreases when B2 stimulated
319
at what dopamine dose do you see effects on the dopamine receptor, beta receptor and alpha receptor
dopamine 0.5-3 mcg/kg/min *promotes renal vasodilation
beta 3-10 mcg/kg/min
alpha >10 mcg/kg/min
320
what is a sympatholetic?
blocks the outflow of sympathetic impulses from the CNS or inhibits release of NOREPI from peripheral sympathetic post ganglionic nerve terminals
321
what are two major CV actions of competitive alpha adrenergic antagonists
-decrease bp secondary to vasodilation
- reflex tachycardia
322
what receptors are inhibited by phentolamine
nonselective antagonist of alpha 1 and alpha 2 receptors
323
what is the major pharmacologic action of phentolamine?
-produces peripheral vasodilation which decrease BP
324
how does phentolamine produce tachycardia
reflects release of norepi from sympathetic post ganglionic nerve terminals owing to alpha 2 blockade
325
how does alpha 2 blockade of sympathetic nerve terminals by an alpha adrenergic antagonist alter release of norepi?
presynaptic blockade of alpha 2 adrenergic receptors increases the release of norepi
326
what kind of drug is prazosin and phenoxybenzamine and how is it used in anesthesia
phenoxybenzamine- long acting alpha adrenergic antagonist (1 and 2)
prazosin- selective alpha 1 antagonist
-used to control bp to remove pheochromocytoma
327
what are 5 side effects of beta blockers
- heart block
-worsening heart failure
-bronchospasm
-coronary artery constriction
-hypoglycemia
328
signs and symptoms of beta receptor antagonist overdose
hypotension
bradycardia
prolonged AV conduction times
wide QRS
seizures
depression
hypoglycemia
bronchospasm
329
what is the treatment of adrenergic antagonist overdose
epinephrine
glucagon
330
how does propanolol decrease myocardial O2 consumption?
-decreasing HR and myocardial contractility
331
what is the purpose of giving beta blocker to angina patients
prevents increase in HR which keeps O2 requirements reduced and prevents angina
332
what are 3 manifestations of abrupt beta blocker withdrawal
tachycardia
hypertension
angina
333
why do tachycardia and HTN develop after abrupt beta blocker withdrawal
beta receptors are upregulated as a result of chronic BB use, they are highly sensitive to catecholamines
334
how is esmolol eliminated and what is the primary use?
- metabolized by plasma esterases
-used for rapid and short term reductions in HR and BP
335
6 contraindications/ cautions for esmolol
-sinus bradycardia
-AV heart blocks
-COPD
-hypotensive
-cardiogenic shock
-heart failure
336
anesthesia considerations for pt with cocaine abuse
-paranoid delusions preop
-hypertensive
-labile BP
-difficult vascular access
-depression following withdrawal
-**acute toxicity seizures vfib and sudden death**
337
what are two alpha 2 agonists
clonidine
dexmetomidine
338
where does alpha 2 agonist work to produce their therapeutic effect
stimulation of alpha 2 receptors of inhibitory neurons in the vasomotor center of the medulla in the brain stem inhibits SNS outflow, this decreases BP
339
how do alpha 2 agonists antagonist the SNS
-alpha 2 receptors found peripherally in the surface membrane of the norepi containing presynaptic nerve terminals,
-stimulation of these receptors decrease the release of norepi,
-decreased release of norepi contributes modestly to clonidine decrease in BP
340
6 clinical uses of clonidine
- preanesthetic med
-prolong effects of regional anesthesia
-diagnose pheochromocytoma
-treat opioid withdrawal
-treat shivering
-protect against perioperative myocardial ischemia
341
how much does pretreatment of clonidine decrease MAC
decreases MAC of inhalation agents by up to 50%
342
3 common side effects of clonidine
-sedation
-bradycardia
-dry mouth
**dont d/c abruptly bc rebound hypertension may occur 8-36 hrs after last dose**
343
how should life threatening hypertension from clonidine withdrawal be treated
-reinstituting clonidine therapy
-administering vasodilating drugs (hydralazine or nitroprusside)
344
should beta blockers be given during clonidine withdrawal
no, may exaggerate the magnitude of rebound HTN by blocking B2 vasodilating effects of catecholamines, can also cause HF
345
what drugs can cause exaggerated rebound HTN of clonidine withdrawal
BB
trycyclic antidepressants
346
anesthesia consideration for chronic clonidine therapy
clonidine likely to promote perioperative hypotehermia
**clonidine and precedex alter central thermoregulation control**
347
name 3 vasodilators that decrease BP by direct effects on vascular smooth muscle independent of alpha or beta receptors?
hydralazine
nitroprusside
nitroglycerin
348
how do nitrovasodilators relax smooth muscle? what substance produced? what enzyme and second messenger are involved?
-nitroprusside and nitroglycerin donate NO
-NO activates the enzyme soluble guanylate cyclase which increases cGMP
-cGMP (second messenger) relaxes vascular smooth muscle, promoting vasodilation and deccreasing BP
349
how does nitroprusside work to decrease BP
decreases both preload and SVR
both lower arterial blood pressure
350
what is the acceptable dose range for nitroprusside?
0.3-10mcg/kg/min
351
what are three ways Cyanide ions can react
1) binding to methemoglobin to for cyanomethemoglobin
2) reaction with thiosulfate in the liver to produce thiocyanide, catalyzed by rhodanese
3) binding to tissue cytochrome oxidase which interferes with normal O2 utilization by the tissues (prevents the formation of ATP)
352
4 hallmark signs of cyanide toxicity
- metabolic acidosis (base deficit)
-cardiac arrhythmias
-increased venous oxygen content due to inhibition of cytochrome oxidase and cells ability to use O2
-tachyphylaxis (having to titrate your drip up)
353
how do you know when tachyphylaxis of nitroprusside has occured?
if patient is resistant to titrate drip up to 10mcg/kg/min for no longer than 10 min
354
if tachyphylaxis occurs with nitroprusside, after dc drip how do you treat cyanide toxicity?
-100% fiO2
1 amp sodium bicarb
give sodium thiosulfate
sodium thiosulfate acts as a sulfur donor and converts cyanide to thiocynate
355
what else can be given to treat cyanide toxicity?
b12- binds to cyanide to form cyanocobalamin
sodium nitrate- converts hemoglobin to methemoglobin which acts as an antidote by converting cyanide to cyanomethemoglobin
356
where is nitroglycerins site of action?
acts primarily on venules, which decreases venous return due to venodilation
357
what is the cardiac benefit for nitroglycerin in treatment of myocardial ischemia?
-reduces myocardial workload decreasing myocardial O2 consumption
-decreases preload, decreases stroke volume, decreases CO to lower BP
358
how does hydralazine lower BP
its a direct relaxant on vascular smooth muscle
-works by hyperpolarizing smooth muscle and direct activation of guanylyl cyclase to produce vasodilation
*dilation greater in arterioles than veins**
359
what can occur in 10-20% of pts treated chronically with hydralazine
systemic lupus erythematosus
360
how can hydralazine cause angina
causes barorecptor reflex increase HR, contractility and CO in response to the lowering of BP; increased myocardial O2 consuption can cause angina
361
how can nitroprusside cause angina?
coronary steal can occur
-its the appearance of ischemic changes on the ECG, decreases in DBP and coronary blood flow produced by nitroprusside can contribute to myocardial ischemia
362
what are class I anti arrhythmic drugs and their subclasses
class I- membrane stabilizers that work by inhibiting fast sodium channels; block sodium channels
ClassIA: quinidine and procainamide
Class IB: lidocaine, tocainide, phenytoin
ClassIC: flecainide and propafenone
363
class I antidysrhythmics used to treat what 3 conditions?
acute and chronic SVT dysrhythmias
slow atrial rate in atrial fib
suppress tachydysrhytmias associated with WPW
364
what are class II antidysrhythmics and what do they do
-they are beta adrenergic antagonists
-they depress automaticity (decrease HR by decreasing spontanous phase 4 depolarization in nodal tissues) and decrease conduction speed of cardiac impulses
365
class III antidysrhythmics and what they do?
-they prolong repolarization by blocking voltage gated potassium channels
ex: amiodarone and sotalol
-prolong the effective refractory period in the SA and AV node, atria, ventricles, and His-Purkinje fibers
366
what are class IV antidysrhythmics and what are they used to treat?
-slow calcium channel blockers
-ex: verapamil diltiazem
-used to treat paroxysmal surpaventricular tachydysrhythmias and control ventricular rates in pts with afib/aflutter
367
List 3 general locations of alpha 2 adrenergic receptors in the body
Presynaptic
Postsynaptic
Nonsynaptic
368
Alpha 2 receptor stimulation on platelets causes
Increased platelet aggregation
369
What effects are produced by alpha 2 stimulation of the locus coeruleus
Sedation and hypnosis
370
Rapid administration of dexmedetomidine can stimulate peripheral postsynaptic alpha 2 receptors in the circulation leading to
Vasoconstriction and hypertension
371
What beta blockers have membrane stabilizing activity?
Propranolol
Carvedilol
372
What beta blocker has intrinsic sympathomimetic activity
Carvedilol
Labetalol
373
What is intrinsic sympathomimetic activity (ISA)
A beta blocker with ISA exerts a partial stimulating agonist action at the beta receptor while at the same time blocking endogenous catecholamines from binding to the receptor
374
What is membrane stabilizing activity (MSA)
The inhibition or abolition of action potential propagation across the cell membrane
BB with MSA act as antiarrhythmics
375
Esmolol IV and infusion dose
IV 10-80mg
Infusion 50-300mcg/kg/min
376
Metoprolol IV and max dose
IV 2.5-5mg
Max dose 15mg
377
phenylephrine bolus and infusion dose
IV bolus 40-100 mcg
infusion 0.15-0.75mcg/kg/min
378
dexmedetomidine iv bolus dose and infusion dose
IV bolus 1mcg/kg
infusion 0.2-0.8 mcg/kg/hr
379
Blood pressure goals in anesthesia
-within 20% of patients baseline
-map>65 systolic >100
380
Which calcium channel blocker does NOT produce negative chronotropic and inotropic effects
Clevidipine
381
What class is phenoxybenzamine and what is it used for
Non selective noncompetitive alpha antagonist
Used almost exclusively in the preoperative management of pheochromocytom to normalize bp and prevent episodic HTN
382
what tissues does lidocaine work on the heart
-delays the rate of spontaneous stage 4 depolarization of ventricular cardiac cells and the His-Purkinje system by preventing or diminishing the gradual decrease in potassium ion permeability during this phase
383
which antidysrhythmic is drug of choice for treatment of ventricular dysrhythmias?
lidocaine
*valley memory master*
384
verapamil and diltiazem slow heart rate by working on what phase in the sino atrial action potential
slowing phase 4 depolarization of the sinoatrial node action potential
385
name 5 drugs or treatments for cardiac dysrhythmias due to digoxin toxicity
-lidocaine
-atropine
-phenytoin
-propanolol
-pacemaker for complete heart block
386
what antidysrhythmic drugs are not local anesthetics but have local anesthetic activity
class I drugs produce sodium channel blockade
386
what 4 drugs should be avoided in a patient being treated with digitalis
-any drug that decreases serum K
-oral antiacids and digoxin increase cardiac glycosides
-beta adrenergic agonists- may increase cardiac dysrhythmias
-IV calcium which may precipitate cardiac dysrhythmias
386
what two drugs are used to treat heart block
atropine or isoproterenol
387
how does adenosine work
blocks conduction of impulses through the AV node by hyperpolarizing the AV nodal cells.
-hyperpolarization occurs because adenosine binds to A1 purinergic receptors which then open potassium channels in these cells and increases the efflux of K from nodal cells, this decreases excitability
388
what is the metabolism and elimination of adenosine
rapidly eliminated by enzymatic clearance (less than 1 min) or via the RBCs and vascular endothelial cells
389
what are ways afib can be treated in anesthesia if required
-if patient stable- amiodarone, beta blockers (propanolol) digitalis
-if pt unstable- synchronized cardioversion withcalcium channel blockers, beta blockers
390
what are the cardiovascular actions of glucagon
it increases myocardial contractility (has positive inotrope effect) and heart rate which increases CO
391
glucagon MOA
binds to glucagon receptors which promotes the formation of cAMP
392
name 5 situations glucagon might be beneficial hemodynamically
-low CO following cardiopulmonary bypass
-low CO with MI
-chronic congestive HF
-anaphylactic shock with refractory hypotension
-excessive adrenergic blockade
393
3 cardiac effects of digitalis
-enhances myocardial contraction
-decreases heart rate
-slows impulse propagation through the AV node
394
what are two uses of digoxin
-treat CHF
-control supraventricular dysrhythmias
395
how does digitalis produce positive inotrope effect
it inhibits the sodium potassium pump
when Na-K pump inhibited Na accumulates in the cell which inhibits the sodium calcium exchange system. Ca accumulates in cardiac cell so contractility increases
396
what phase in cardiac cycle does digitalis work
phase 4
-decreases automaticity and lowers HR
397
what 3 electrolyte disturbances enhance digitalis toxicity
-hypokalemia
-hypercalcemia
-hypomagnesia
398
why does hypokalemia enhance digitalis toxicity
it allows increased binding of digitalis to Na-K ATPase pump in cardiac cells resulting in excessive drug effect
399
why should hyperventilation be avoided during anesthesia for the pt taking digitalis
hyperventilation causes hypokalemia which causes increase risk of digitalis toxicity
400
what are 5 uses of calcium channel blockers
-treat supraventricular tachy dysrhytmias
-treat essential HTN
-treat coronary vasospasm
-treat angina
-treat cerebral vasospasm
401
how does verapamil effect SVR and HR
decreases both SVR by relaxing vascular smooth muscle and HR
402
what actions does verapamil potentiate in anesthesia drugs
potentiates the actions of nondepolarizing and depolarizing muscle relaxants
403
what 4 patient groups is verapamil contraindicated
-wolff parkinson white syndrome
-sick sinus syndrome
-AV block
-heart failure
404
why is verapamil a poor drug choice for patient with WPW
it may increase conduction velocity in the accessory tract and increase HR excessively
405
what drugs partially reverse CCB overdose
IV calcium and dopamine
406
What are some examples of alternative medicine
Acupuncture
Massage therapy
Meditation
Aromatherapy
Relaxation therapy
Reflexology
Float pool
Herbal medicines
407
What is the current federal organization that does research on herbal medication
National Center for Complimentary and Integrative Health
408
What are two ASA recommendations for all herbal meds
-d/c two weeks before surgery
-all anesthesia providers should be aware of herbal medications and potential perioperative interactions
409
Anesthesia implications for herbal meds
-direct and indirect health effects
-intrinsic pharmacological effects
-pharmacodynamic interactions
1. Alteration of drug receptors
2. Pharmacokinetic interactions altering absorption/metabolism/elimination of anesthetic meds
-more meds=more potential drug interactions
410
What are direct health effects of herbal meds
-direct impact on physiology
-drug-herbal interaction
-allergic reactions
-hypertension (ephedra)
-coagulopathy (ginkgo)
411
What 11 supplements have anesthesia implications
-Dong Quai
-Echinacea
-Ephedra
-feverfew
-garlic
-ginger
-ginkgo biloba
-ginseng
-kava
-papain
-saw palmetto
-st johns wort
-valerian
412
what direct effect does ephedra have on pt health
HTN
413
what direct health effect does ginkgo biloba have
coagulopathy
414
what if the effect of herbal meds on CYP450
can inhibit or induce leading to alerted metabolism
415
what is dong quai used for
migraines
anemia
HTN
menstrual cramps
menopausal symptoms
416
what drug is dong quai related to
coumadin derivative
417
what is echinachea used for
viral bacterial and fungal URI
chronic wounds
arthritis
decrease effects of chemo
418
what does echinachea stimulate
macrophages
NK cells
419
adverse effects of echinachea
GI upset
headache
dizziness
unpleasant taste
REJECT RENAL TRANSPLANT
INHIBITS CYP450
antagonizes immunosuppressants
>8wks causes immunosuppression
420
what is ephedra used for
weight loss
energy
bronchodilator
URI
asthma
bronchitis
aphrodisiac
421
what are active metabolites of ephedra
ephedrine
psuedoephedrine
methylephedrine
norepinephrine
422
what does prolonged use of ephedra lead to
catecholamine depletion
hemodynamic instability
tachyphylaxis
423
adverse effects of ephedra
palpitations
htn
tachycardia
hyperthermia
seizures
**STROKE and MI**
cardiomyopathy
severe vasoconstriction
cerebral&coronary artery vasospasm
myocardial hypersensitivity
424
effects of MAOI and ephedra
hyperpyrexia
HTN
coma
425
what is feverfew used for
migraines
fever
menstrual irregularities
426
what is feverfew contraindicated in
allergies to chamomile ragweed and yarrow
warfarin use (increased inhibition of platelet activity)
427
what is ginger used for
nausea and vomiting
motion sickness
anti-inflammatory ( arthritis)
428
side effects of ginger
inhibits platelet aggregation (bleeding)
arrhythmias
cns depression
potentiation of CCBs
429
what is garlic used for
infection
tumor
DM
HTN
HLD
atheroschlerosis
430
what does garlic inhibit
biosynthesis of cholestrol
431
what are adverse affects of garlic
nausea
hypotension
allergy
bleeding
decreased blood sugar
432
what drugs does garlic interact with
anticoags like coumadin, ASA and NSAIDS
433
what is ginseng used for
stimulant
tonic
diuretic
immunomodulation
mood elevation
hypoglycemia
may lower cholesterol
increased stress tolerance
increased vitality
434
what drugs interact with ginseng
phenelzine (nardil)
warfarin
heparin
ASA
NSAIDs
caffeine
435
what conditions are contraindicated for ginseng
bipolar
psychosis
cardiac disease
HTN
caffeine use
stimulant use
436
what is gingko biloba used for
Alzheimer disease
dementia
memory loss
vasodilator
decreases fibrinogen
inhibits platelet aggregation
bronchodilator
increased coronary blood flow
increased cardiac contractility
437
how does ginkgo biloba improve vascular conditions
vasodilation
decreased viscosity
438
what are adverse effects of ginkgo biloba
gi upset
headache
bleeding
439
what are drug interactions with ginkgo biloba
anticoagulants
NSAIDs
ASA
warfarin
heparin
440
what is kava kava used for
anxiety
sedative
sleep enhancer
anticonvulsant
central muscle relaxant
441
how does kava kava effect anesthesia
increased anesthetic dose with long term
442
how does kava kava affect sodium/calcium channels
inhibits them
leading to a decrease in SVR
443
what are adverse effects of kava
increased effects of ETOH, barbituates/benzo pyschopharmacologics
prolongs anesthetics
444
what is papain used for
treat dyspepsia
inflammatory disorders
hemorrhoids
intestinal worms
diarrhea
tumors
resp infections
topical for psoriasis, ringworm, wounds, ulcers and infections
445
what drug is papain contraindicated for concurrent use with
warfarin
446
what is saw palmetto used for
BPH
diuretic
urinary antiseptic
447
what is an adverse effect of saw palmetto
potentiation of barbituates
448
what is st johns wort used for
anxiety and depression
449
what are adverse effects of st johns wort
GI upset
fatigue
dizziness
confusion
headache
photosensitivity
450
what can st johns wort interact with
tricyclic antidepressants
MAOIs
digoxin
451
how does st johns wort affect metabolism
induces CYP450 which decreases coumadin effectiveness
delays emergence from anesthesia
452
what does valerian root treat
anxiety
restlessness
sleep aid
453
what drug is in almost all herbal sleep aids
valerian root
454
what are adverse effects of valerian root
stomach upset
tremor
headache
cardiac disturbances
PROLONGED ANESTHESIA EMERGENCE
455
how does curcumin longa (tumeric) effect metabolism
inhibits CYP450 decreasing metabolism
456
how does tumeric effect antacids
interferes with action by increasing stomach acid
457
what is garcinia cambogia used for
weight loss
DM
HLD
458
how does garcinia combogia effect metabolism
induces CYP450 increasing metabolism
459
what herbal drugs delay emergence from anesthesia
valerian root
ginger
st johns wort
saw palmetto
kava kava
460
what herbal drugs increase bleeding
dong quai
feverfew
ginger
garlic
echinachea
ginkgo biloba
tumeric
saw palmetto
ginseng
papain
valerian root
kava kava
461
what herbal drugs have CV effects
ephedra
ginkgo biloba
ginger
kava kava
garcinia cambogia
462
atropine - plant derived and use
atropa belladona
anticholinergic
463
curare- plant derived and use
chondrodendon tomentosum
neuromuscular blockers
464
digoxin- plant and use
foxglove
anti arrhythmic
465
ephedrine- plant and use
ephedra sinica
CNS stimulant
466
morphine plant and use
poppy
analgesic
467
scopolamine- plant and use
datura metel
anti-emetic
468
caffeine- plant and use
camelia sinesis
CNS stimulant
bronchodilator
469
cocaine- plant and use
erythoxylon coca
local anesthetic
470
what herbal drugs induce CYP450
st johns wort
garcinia cambogia
Garlic in some isoforms
Ginseng
471
What neurotransmitters can increase neuronal excitability and seizure activity
Glutamate
Aspartate
472
How do we think anti-epileptics work?
By decreasing neuronal excitability or enhancing the inhibition of neurotransmitters
1. Altering electrical activity in the neurons by affecting ion currents like (Na, K, and Ca) in the cell membrane
2. Altering chemical activity of neurotransmitters like GABA in synapse
473
Carbamazepine (Tegretol) MOA and effective uses
MOA: sodium ion channel blockage
Effective uses:
-convulsive and nonconvulsive seizures
-trigeminal and glossopharyngeal neuralgia
474
Anesthesia specific considerations for carbamazepine
-hepatic enzyme inducer-accelerates the metabolism of lipid soluble drugs (ex: higher doses of prop needed
-creates resistance to NDMB/may need higher doses roc/vec
-plasma protein bound medication- pts with altered protein states/albumin like liver failure and malnutrition
475
Most Side effects of neuropsych drugs
Sedation
Vertigo/dizziness
Diplopia
Hyponatremia/electrolyte imbalance
GI disturbances
Headache
Ataxia
Weakness
476
MOA of phenytoin
Blocks voltage gated Na channels (membrane stabilization)
477
MOA of carbamazepine
Blocks voltage gated Na channels (membrane stabilization)
478
MOA of gabapentin
Inhibits the alpha 2 delta subunit of voltage gates Ca channels in the CNS
479
6 side effects of phenytoin
Dysrhythmias
Gingival hyperplasia
Aplastic anemia
Cerebral vestibular dysfunction
Steven Johnson syndrome
Birth defects
480
Do gabapentinoids produce respiratory depression
They can exacerbate respiratory depression when combined with an opioid
481
Which anticonvulsants do not induce hepatic enzymes?
Gabapentinoids
482
What effect does Diltiazem have on the heart?
Negative dromotrope
Prolongs AV node conduction
Used to treat afib a flutter and supraventricular tachycadia
Is a negative chronotrope at SA node and negative inotrope in cardiac muscle
483
which group of drugs interfere with the metabolism of adrenergic neurotransmitters?
MAOI bind to and inhibit monoamine oxidase
the result is an increase in the levels of adrenergic neurotransmitters in brain, heart, intestines and plasma
484
name 4 non selective MOAI
isocarboxazid
phenelzine
moclobemide
selegiline
485
what drugs are prohibited in pt taking MAOI
tricyclic antidepressants
opioids (especially meridipine)
indirect acting sympathomimetics (ephedrine)
fluoxetine
ketamine
nasal decongestants
epi in local anesthetics
all these can cause severe HTN, CNS excitation, seizures and death
486
what effect does st johns wort have on the liver?
induces cyp450, doubling its activity
487
what are two perioperative drugs levels may be altered in patient taking st johns wort
warfarin
NSAIDs
488
why do you want to check lithium levels in a patient
toxic levels >1.5mEq/L
check sodium levels before surgery because they could be decreased and avoid diuresis in these patients
489
what are three major mechanisms that cause arrythmias
enhanced automaticity
re entry
triggered
490
explain enhanced automaticity
when any cell outside of the SA node (includes AV node/purkinje fibers) become more excitable and generates an action potential at a rate faster than our normal cardiac pacemaker cells
could be due to increased sympathetic tone or abnormal electrolyte concentrations
491
explain re-entry arrythmias
the cardiac arrhythmia occurs in the presence of a re entry circuit in the heart; the electrical signal follows a circular pathway repeatedly which perpetuates abnormal rhythms
492
key factors of re-entry arrhythmias
-loop/circuit of electrical activity
-unidirectional blocks
-presence/risk of abnormal conduction pathways
examples of these are aflutter, AV re-entry tachycardia, AV nodal re-entry tachycardias, vtach, WPW
493
explain triggered arrhythmias
we trigger or an outside triggers an arrhythmia
ex: inhaled anesthetics, IV meds, reaction to meds related to anaphylaxis
494
what are the most common causes of arrhythmias in anesthesia
-hypoxemia
-certain drugs
-bradycardia
-altered sympathetic nervous system activity
-myocardial ischemia
-acid/base abnormalities
-electrolyte imbalances
495
MOA of class 1 antiarrhythmics and examples
sodium channel blockers
MOA: blocks Na channels in the cardiac cell membrane inhibiting the influx of Na ions during the depolarization phase of an action potential
ex: procainimide (class 1A) moderate Na and K channel blockade
Lidocaine (1B) weak Na channel blockade
flecainimide (1C)- marked Na channel blockade but minimal effect on repolarization
used to treat ventricular arrhythmias and atrial arrhythmias
496
MOA of Class 2 antiarrhythmics and examples
beta blockers
MOA: block adrenergic receptors which leads to decrease in effects of sympathetic stimulation; blocks effects of catecholamines norepi/epi
Ex: metoprolol and esmolol (decreases rate of depolarization)
used to reduced HR and treat atrial and ventricular arrhythmias
497
MOA of class 3 antiarrhythmics and examples
potassium channel blockers
MOA: work by blocking K channels prolonging the action potential of the duration of the refractory period;
ex: amiodarone
used to treat atrial and ventricular arrhythmias, used when other classes not effective
498
MOA of class 4 antiarrhytmics and examples
calcium channel blockers
MOA: inhibits slow calcium channels (L type); blocks ca channels, reduces influx of Ca ions during the depolarization phase of an action potential
ex:
class A: effects atrial tissue- Verapamil
class B: effects ventricular tissue- diltiazem
used to treat supraventricular arrhythmias, afib and aflutter
499
what phase does sodium channel blockers (class 1) work on
atrial/ventricular phase 0 ( depolarization)
slow conduction and suppress maximum upstroke velocity of cardiac action potential
500
what phase does beta blockers (class 2) work on
**phase 4 SA/AV node**
501
what phase does potassium channel blockers (class 3) work on
myocyte and SA/AV node phase 3 (repolarization)
prolong repolarization by increasing duration of cardiac action potential and refractory period; prolongs QT
502
what phase does calcium channel blockers (class 4) work on
phase 0 and 4 of SA/AV
503
how does procainimide work
lengthens the action potential duration and refractory period by Na channel inhibition; prolongs repolarization
treats: WPW, PVCs, paroxysmal vtach
504
how does lidocaine work
shortens action potential duration and refractory period; delays rate of spontaneous phase 4 depolarization by preventing or diminishing the gradual decrease in K ion permeability
treats: ventricular arrhythmias and reentry cardiac arrhythmias
**not effective in treating supraventricular tachyarrhythmias**
505
What is the first line drug for myoclonic seizures
Benzodiazepines
Midazolam
506
What is the first line treatment for status epilepticus
Midazolam
2.5-5mg IV up to 15mg
IV, intranasal, buccal
507
What is the management for status epilepticus
-upper airway management
-IV access
-drug therapy benzodiazepines
-continuous infusion of AED med to stop seizure activity
508
Why does cardiac muscle not contract during MH crisis?
RYR1 receptor is only on skeletal muscles and not cardiac muscles
509
What herbal drugs inhibit cyp450
Echinacea
Curcumin longa (tumeric)
Ginkgo biloba
Garlic in some isoforms
Ginger
Valerian root
Kava kava
510
What antiarrrhythmic do we not use in WPW
Digoxin
511
MOA of opioid agonist
Bind to opioid receptors coupled to G proteins that inhibits adenyl cyclase
-inhibits voltage gated Ca channels
-activates and opens k channels
>intracellular k increases which decreases neutrotransmission
Opioid receptors are mu, kappa, delta
512
Explain Mu receptors and their subtypes
Mu: primary receptors for analgesia and adverse effects
Mu1: analgesia
Mu2: respiratory depression, bradycardia, dependence
513
Define kappa pain receptors
-inhibit neuro transmission via type Ca channels
-responsible for dysphoria and diuresis
514
Define delta receptors
Modulate Mu receptor activity
Is the receptor for endogenous opioids (endorphins etc)
515
How does class 1A effect
-depolarization phase 0
-conduction velocity
-effective refractory period
-action potential duration
-automaticity
-p-r duration
-QRS duration
-QTc duration
**think slow ventricles**
-depolarization phase 0: ⬇️
-conduction velocity: ⬇️
-effective refractory period:⬆️⬆️⬆️
-action potential duration⬆️
-automaticity⬇️
-p-r duration✖️
-QRS duration⬆️
-QTc duration⬆️⬆️⬆️
516
How does class 1B effect
-depolarization phase 0
-conduction velocity
-effective refractory period
-action potential duration
-automaticity
-p-r duration
-QRS duration
-QTc duration
**think small spaces out action potentials**
-depolarization phase 0✖️
-conduction velocity✖️
-effective refractory period⬇️
-action potential duration⬇️
-automaticity⬇️
-p-r duration✖️
-QRS duration✖️
-QTc duration✖️or ⬇️
517
How does class 1C effect
-depolarization phase 0
-conduction velocity
-effective refractory period
-action potential duration
-automaticity
-p-r duration
-QRS duration
-QTc duration
**think long slow ekg**
-depolarization phase 0⬇️⬇️⬇️
-conduction velocity⬇️⬇️⬇️
-effective refractory period⬆️
-action potential duration⬆️
-automaticity⬇️
-p-r duration⬆️
-QRS duration⬆️⬆️⬆️
-QTc duration⬆️
518
How does class 2 effect
-depolarization phase 0
-conduction velocity
-effective refractory period
-action potential duration
-automaticity
-p-r duration
-QRS duration
-QTc duration
**think slow electricity**
-depolarization phase 0 ✖️
-conduction velocity⬇️
-effective refractory period⬇️
-action potential duration⬆️
-automaticity⬇️
-p-r duration✖️ or ⬆️
-QRS duration✖️
-QTc duration⬇️
519
How does class 3 effect
-depolarization phase 0
-conduction velocity
-effective refractory period
-action potential duration
-automaticity
-p-r duration
-QRS duration
-QTc duration
**think long ekg and long refractory action potentials**
-depolarization phase 0 ✖️
-conduction velocity⬇️
-effective refractory period⬆️⬆️⬆️
-action potential duration⬆️⬆️⬆️
-automaticity⬇️
-p-r duration⬆️
-QRS duration⬆️
-QTc duration⬆️⬆️⬆️
520
How does class 4 effect
-depolarization phase 0
-conduction velocity
-effective refractory period
-action potential duration
-automaticity
-p-r duration
-QRS duration
-QTc duration
**think short APs, long PRs**
-depolarization phase 0✖️
-conduction velocity✖️
-effective refractory period✖️
-action potential duration⬇️
-automaticity✖️
-p-r duration✖️ or ⬆️
-QRS duration✖️
-QTc duration✖️
521
What is the pro type drug for class 1a
Procainamide
522
What is the pro type drug for class 1B
Lidocaine
523
What is the pro type drug class 1C
Flecainide
524
What is prodrug class 2
Beta blockers
Metoprolol and esmolol
525
Protype drug for class 3
Amiodarone
526
Protype drug class 4
Diltiazem- ventricle
Verapamil- atrial
527
What anti arrhythmic effects thyroid function
Amiodarone
528
Anesthesia consideration for nitroglycerin
Not recommended for aortic stenosis and hypertrophic cardiomyopathy
529
Which type of sympathomimetics have greatest effect on beta receptors
Synthetic catecholamines
530
Which type of sympathomimetics have the least effect on alpha receptors
Synthetic catecholamines
531
Which synthetic non catecholamine has the greatest affinity for alpha receptors
Phenylephrine
532
What is the first step if a patient has sudden elevated HR and BP
-check monitors/equipment
-deepen anesthetic
-treat pain
533
How do you treat concurrent increased HR and BP
Labetalol
534
What medication can you use to treat a short painful stimulation that is non opioid
Esmolol- can be used for intubation/DL
535
What happens if you give dantrolene and verapamil
Hyperkalemia
Myocardial depression
Hypotension
536
What channels do local anesthetics block
Sodium
537
What can happen if pt on sildenafil doesn’t stop use before periop
Sudden irreversible loss of vision
Severe hypotension (treat with pressors)
Stop med 7 days before surgery
538
What are beta blocker contraindications
Vasospasm
Toxic with cocaine
Heart block
Catecholamine induced HTN/tachy
539
What does digitalis inhibit
Na K pump
540
4 Ps of CCB
Platelets inhibited
Pressure decreased
Paralytics increased
Potassium increased
541
What neuropsych drugs are hepatic enzyme INDUCERS
Carbamazepine
Lamotrigine
Phenobarbital
Phenytoin
542
What neuropsych drugs DO NOT induce hepatic enzymes
Levetiracetam
Gabapentin
543
Formula for MAP
MAP=COxSVR
MAP=(SBP+2DBP)/3
544
Formula for MAP
MAP=COxSVR
MAP=(SBP+2DBP)/3
545
When is phenytoin used as an antiarrhythmics
To suppress ventricular arrhythmias due to digitalis toxicity
546
Does valproic acid induce or inhibit liver enzymes?
Inhibits
547
What is the first line benzo for myoclonic seizures
Clonazepam
548
What antiemetics are contraindicated for Parkinson’s patients
Prochlorperazine
Metoclopramide
Promethazine
549
Is levadopa stopped in the perioperative area?
NO, abrupt dc of levadopa may result in parkinsonism hyperpyrexia syndrome
S/s: rigidity, pyrexia, autonomic instability, decreased LOC
*looks like MH*
550
Ginseng proposedMOA
-augmentation if adrenal steroidogenesis
-increased IgGand IgM production
-increased interferon production
-enhancement of cell mediated immunity
-enhancement of natural killer cell activity
551
Ginseng proposedMOA
-augmentation if adrenal steroidogenesis
-increased IgGand IgM production
-increased interferon production
-enhancement of cell mediated immunity
-enhancement of natural killer cell activity
552
Which anesthesia meds are seizure inducing
Ketamine
Etomidate
Methohexital
Inhaled: sevo, nitrous oxide
Meperidine
