IV Sedatives Flashcards by Kaitie Kading

Barbiturates increase the _____ of the opening of the chloride channel

duration

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Thiobarbiturates have a ____ molecule in the 2nd position which increases lipid solubility and ____.

sulfur, potency

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Oxybarbiturates have a ____ molecule in the 2nd position

oxygen

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Adding a phenyl group at the 5th carbon increases the ______. Which med is this?

Anticonvulsant effect. Phenobarbital

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What is Thiopental mechanism of action?

GABA-A agonist Depresses reticular activating system in the brainstem.

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What is the following for Thiopental:
Dose:
Onset:
Duration:
Clearance:
Side effects:

Dose: 2.5-5mg
Onset: 30-60 sec
Duration: 5-10 min
Clearance: Liver P450 enzyme
S/E: hypotension, histamine release, respiratory depression, bronchoconstriction, decrease in cerebral blood flow and metabolic demand. No analgesia

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What is the most common and dangerous type of porphyria

Acute Intermittent Porphyia

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What causes porphyria?

Defect in heme synthesis that promotes the accumulation of heme precursors

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What things make acute intermittent porphyria worse?

ALA synthase, emotional stress, prolonged NPO status, CYP450 induction

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What are signs and symptoms of porphyria?

Severe abdominal pain, N/V, anxiety, muscle weakness, seizures, coma

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What are drugs to avoid with porphyria?

Barbs
Etomidate
Ketamine
Ketorolac
Amio
Many Ca Channel Blockers
Birth Control pills

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What types of anesthetic management is done for porphyria?

hydration!
Glucose
Heme arginate
Prevent Hypothermia
consider regional

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What are the following for Propofol?

MOA:
Dose:
Onset:
Duration:
Clearance:

MOA: GABA-A agonist
Dose: 1-2mg/kg
Onset: 30-60sec
Duration: 5-10 min 
Clearance: liver P450

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What are side effects of Propofol:

Cardiac: Decreased BP, SVR, preload, contractility
Respiratory: less sensitive to increasing CO2, decreased TV
CNS: decreased CMRO2, ICP, IOP
green/cloudy urine

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The clearance of Propofol exceeds what the liver is able to handle, how else is it excreted?

the lungs

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About how long does it take to have peak brain concentration with Propofol?

1 min

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What are risk factors for Propofol Infusion Syndrome (PIS)

Propofol dose >4mcg/kg/hr (67mcg/kg/min)
Infusion >48hr
Sepsis
Continuous catecholamine infusions
high-dose sterioids
significant cerebral injury

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What are s/s of propofol infusion syndrome?

acute, refractory bradycardia that leads to asystole plus one of the following:
metabolic acidosis
rhabdo
enlarged fatty liver
renal failure
HLD
lipemia**early clinical sign

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What is the treatment for propofol infusion syndrome?

stop propofol
maximize gas exchange
cardiac pacing
Glucagon
ECMO
CRRT
Phosphodiesterase inhibitors

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What is Methohexital used for?

ECT

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Phenobarbital is excreted through the ___ which is different than other barbiturates, which are metabolized by______

urine, P450 enzymes

What is the following for Propofol:

MOA:
Dose:
Onset:
Duration:
Clearance:

MOA: GABA-A agonist
Dose: 1-2mg/kg
Onset: 30-60 sec
Duration: 5-10 min
Clearance: P450 and lungs

What are risk factors for propofol infusion syndrome (PIS)?

High propofol dosing (>4mcg/kg/hr or 67mcg/kg/min)
Duration >48hr
Sepsis
Continuous catecholamine infusions
High dose sterioids
Significant cerebral injury

What are side effects of propofol infusion syndrome?

Acute refractory bradycardia that leads to asystole + one of the following:

Metabolic acidosis
Rhabdo
Enlarged fatty liver
Renal failure
HLD
lipemia (early sign)

What is the treatment for propofol infusion syndrome?

``` stop propofol maximize gas exchange cardiac pacing Glucagon ECMO CRRT Phosphodiesterase inhibitors ```

What is the following for Etomidate: ``` MOA: Dose: Onset: Duration: Clearance: ```

``` MOA: GABA-A agonist Dose: 0.2-0.4mg/kg Onset: 30-60 sec Duration: 5-15 min Clearance: P450 and plasma esterases ```

What are the benefits of Etomidate?

More cardiac stability than propofol, less respiratory depression, short half life

When should you use caution with Etomidate?

It decreases adrenocortical function for 5-8 hr so use with causes in pts with sepsis or acute adrenal failure. increased mortality rate. Also avoid if patient has had acute intermittent porphyria

What do benzos do to let Chloride in?

The frequency of the channel opening increases

What is the following for Midazolam: ``` MOA: Dose: Onset: Duration: Clearance: Metabolite: ```

MOA: GABA-A agonist, increased frequency of channel opening Dose: 0.1 mg/kg Onset: 30-60 sec Duration: 20-60 min Clearance: Liver & intestines P450 enzymes Metabolite: 1-hydroxymidazolam (half potency, renal failure prolongs effect)

Respiratory effects of midazolam:

induction dose causes respiratory depression. Opioids potentiate effect.

CNS effects of midazolam:

Anticonvulsant Antianxiety amnesia antispasmodic

Uses for diazepam:

anticonvulsant, antispasmodic, prevent emergence delirium after ketamine

How long does it take for Lorazepam to reach peak effect?

20-30 min (slow onset)

How long does Lorazepam work?

6-10 hrs

What is a short acting benzo that is used for helping fall asleep?

Triazolam

What is the reversal for benzos and what is the MOA?

Flumazenil, GABA-A antagonist

What is the dosing for Flumazenil?

0.2mg IV, titrated to 0.1mg Q1min.

What is the following for Ketamine: ``` MOA: Dose: Onset: Duration: Clearance: Metabolite: ```

``` MOA: NMDA antagonist Dose: Induction: 1-2mg/kg, Maint: 1-3mg/kg Onset: 30-60 sec Duration: 10-20 min Clearance: Liver P450 Metabolite: Norketamine ```

Does ketamine decrease the respiratory drive?

No!

What are cardiac effects of Ketamine?

``` increased: SNS tone Cardiac output HR SVR PVR ``` myocardial depressant

What are respiratory effects of Ketamine?

Bronchodilation Maintains respiratory drive Increased oral and pulmonary secretions (may give glyco to avoid)

What are CNS effects of Ketamine?

``` Increased: CMRO2 blood flow ICP IOP EEG activity Nystagmus Emergence Delirium ```

What are some other uses and effects of Ketamine?

Treatment of depression, chronic use can cause ulcerative colitis, avoid with pts with porphyria, lowest amount of protein binding, relieves somatic pain >visceral pain, good for frequent dressing changes and pre-existing chronic pain syndromes

What is the following for Dexmedetomidine? ``` MOA: Dose: Onset: Duration: Clearance: ```

MOA: Alpha-2 agonist, decreased norepi released and inhibits locus coeruleus in the Pons Dose: bolus: 1mcg/kg over 10 min, maint: 0.4-0.7 mcg/kg/hr Onset: 10-20 min Duration: 10-30 min after infusion Clearance: liver P450 enzymes

What are cardiac effects of Dex?

bradycardia and hypotension. Can get hypertension right after bolus dose

What are respiratory effects of Dex?

None

What are CNS effects of Dex?

decreased blood flow, easily aroused, no amnesia

What are some other effects of Dex?

impairs thermoregulatory response (should shiver but dont) decreased emergence delirium in children analgesia d/t decreased substance P and glutamate release in dorsal horn Useful for wake up tests

What is the reversal for Scopolamine?

Physostigmine