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KM (Spring 2024) COPY of Anesthesia Pharm (Spring 2023) > *MAGA (Exam II) > Flashcards

*MAGA (Exam II) Flashcards

1
Q

What are the components of today’s Multimodal practice?

A
  • Preoperative Fluid
  • Carbohydrate Loading
  • Short Acting Anesthetic Agents
  • Opioid Sparing
  • Temperature Management
  • Cerebral/neuromuscular

S2

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2
Q

What are Nonopioid Alternatives for the treatment of pain?

This is a list

A
  • PT & OT
  • Massage Therapy
  • Acupuncture
  • Chiropractic Care
  • Osteopathic Manipulative Treatment (OMT)
  • Behavioral Interventions
  • Topical Treatments and Medications
  • Cold & Heat
  • Exercise
  • Weight Loss
  • Diet and Nutrition
  • Yoga & Tai Chi
  • TENS
  • OTC Medications
  • Interventional Pain Management
  • Nonopioid Anesthesia

S11

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3
Q

What refers to the anesthetic technique of using medications to provide anesthesia and post-operative pain relief in a way that does not require opioids?

A

Nonopioid Anesthesia

S11

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4
Q

What is the pain response pathway? (5)

A

(this was in the pain pathway slide set too)

S17

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5
Q

What is the MOA of Gabapentin?

A

GABA analogue
(not act like GABA)

Binds voltage gated Ca++ channels:
enhances descending inhibition
inhibits excitatory neurotransmitter release

S25*

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6
Q

Is Gabapentin lipid soluble?
What percentage protein-binding occurs?
What’s it’s E 1/2 time?

A
  • Yes, Lipid soluble
  • 0% protein-bound
  • Brief E 1/2 time – need redosing required

S25

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7
Q

Does Gabapentin have any drug-drug interactions?

A

No drug interactions

S25

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8
Q

What are indicated uses for gabapentin?

A
  • Seizures
  • Neuropathic pain
  • Chronic pain syndromes.

S26

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9
Q

Regarding Gabapentin’s preemptive analgesia, What 3 studies/ procedures is it used in?

A
  • Spine surgeries
  • Orthopedic procedures
  • Major abdominal procedures.

S27

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10
Q

What is the PO dose of preemptive Gabapentin?
When should we give it?

A

300-1200mg PO
1-2 hrs prior to OR

start slow then build up

S27

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11
Q

For Preemptive Gabapentin, what patient population is it contraindicated for?

A
  • MG and Myoclonus patients
  • Reduce dose in elderly patients

S27

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12
Q

What are Gabapentin’s side effects?

A

Think ↑GABA effects

  • Somnolence
  • fatigue
  • ataxia
  • vertigo
  • GI disturbances: constipation
  • abrupt withdrawal in seizure pts (when Gaba is used as an antiepiliptic) –> causing seizures
  • wt gain

S29

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13
Q

Evidenced based slide

What evidence based conclusion was found with the study “Efficacy of preoperative gabapentin in spinal surgery: a meta-analysis of randomized controlled trials”

A

despite of 10 RCTs and low sample size, Gabapentin is:
* effective in reducing post operative opioid consumption
* it also lessen the side effects after spinal surgery
* lower dose should be given to elderly

S30

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14
Q

What are the effects of NSAIDs?

A
  • Decrease activation of peripheral nociceptors
  • No addictive potential
  • Preemptive analgesia
  • Absence of ventilatory depression
  • Less nausea and vomiting
  • Absence of cognitive effects
  • Long duration of action

S32

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15
Q

What enzyme catalyzes the synthesis of prostaglandins?

A

COX (Cyclooxygenase)

S33

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16
Q

This form of COX is responsible for gastric protection, hemostasis, and renal function…

A

COX-1

S33

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17
Q

COX-1 or COX-2?

Ubiquitous, “physiologic”, inhibition of this enzyme is responsible for many adverse effects.

A

COX-1

S33

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18
Q

COX-1 or COX-2?

Pathophysiologic, expressed at sites of injury, not protective.

A

COX-2

S33

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19
Q

COX-2 propagation is responsible for which symptoms?

A

Pain, inflammation, and fever

S33

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20
Q

What are the three main properties of NSAID drugs?

A

Analgesic
Anti-inflammatory
Antipyretic

S34

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21
Q

Are the following drugs non-specific or COX-2 selective?

–Ibuprofen, naproxen, aspirin, and ketorolac–

What gastric symptomology would be seen with administration of these drugs?

A

Non-Specific

Increased gastric irritation with these drugs

S34

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22
Q

Celecoxib (Celebrex), Rofecoxib (Vioxx), Valdecoxib (Extra), Parecoxib (Dynastat) are all examples of what?

A

COX-2 Selective NSAIDs

S34

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23
Q

Do COX-2 selective NSAIDs effect platelets?

A

No

S35

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24
Q

Because COX-2 selective NSAIDs have no effect on platelets, this would increase the chance of what pathology?

A

Clotting (think MI and CVA)

S35

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25
Q

COX-2 selective and nonspecific inhibitors have _____________ analgesia

A

Comparable

S35

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26
Q

What was the first COX-2 inhibitor that decreases PG synthesis?

A

Celecoxib (Celebrex)

S36

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27
Q

What is the dosage for Celebrex?

A

200 to 400 mg PO QD

S36

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28
Q

Celebrex reaches its peak in…

A

3 hours

S36

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29
Q

What is the MOA for Ofirmev?

A
  • Reduces prostaglandin metabolites
  • No significant anti-inflammatory property
  • Analgesic/antipyretic

S38

30
Q

What is the contraindication of Ofirmev?

A

Hepatic Dysfunction

S38

31
Q

What is the dose and max dose of Ofirmev?

A

1000 mg IV Q4-6H
max 3000-4000 mg QD

*make sure to report administration to PACU!

S38

32
Q

What is the peak of Ofirmev in PO and IV?

A

PO: 1-3 hours
IV: 30 mins to 1 hour

S38

33
Q

What is the duration of Ofirmev?

A

6 - 8 hours

S38

34
Q

What is the MOA of Ketorolac?

A

Inhibits PG synthesis by inhibiting COX 1 and COX 2

Potent analgesic property
Only moderate anti-inflammatory
May potentiate opioid antinociception

S40

35
Q

What are some contraindications to consider when giving Toradol?

A
  • Severe Renal impairment
  • Risk for bleeding – low platelet count
  • CAD
  • CABG
  • Pregnant
  • NSAID allergy
  • Allergy to Tylenol

S40

36
Q

What is the peak of Ketorolac?

A

45 to 60 minutes IV

S40

37
Q

What is the dose and max dose of Ketorolac?

A

Dose: 15 to 30mg q6h (1/2 dose in elderly)
Max Dose: 60-120mg QD

S40

38
Q

Ketorolac has no effects on what?

A
  • biliary tract
  • ventilatory/cardiac depression

S40

39
Q

What is the MOA of Ibuprofen?

A
  • anti-inflammatory
  • analgesic
  • antipyretic
  • inhibits COX 1 and 2

S41

40
Q

What is the contraindication for Ibuprofen?

A
  • Allergies to NSAIDs
  • CABG
  • bleeding ulcers, etc

S41

41
Q

What is the dose and max dose of Ibuprofen?

A

200 to 800 IV over 30 mins Q6H PRN
max: 3200 mg/day

S41

42
Q

What is the peak of Ibuprofen?

A

1 - 2 hours

S41

43
Q

Where is Ibuprofen excreted?

A

Urine and Bile

S41

44
Q

What short acting anesthestic agents are used for multimodal practice?

A
  • Propofol (Diprivan)
  • Ketamine

S42

45
Q

What are the doses for Lidocaine?
What to monitor for?

A

Initial bolus = 1 to 2 mg/kg IV over 2 - 4 min

Drip = 1 to 2 mg/kg/hour
terminated at 12-72 hours

monitor: cardiac, hepatic, & renal dysfunction

S44

46
Q

Lidocaine plasma concentration of ____ causes what?

1-5 mcg/ml = ?

5-10 mcg/ml = ?

A

1-5 = analgesia

5-10 = circum-oral numbness; tinnitus; skeletal muscle twitching; systemic HYPOtension; myocardial depression

S45

47
Q

Lidocaine plasma concentration of ____ causes what?

10-15 mcg/ml = ?

15-25 mcg/ml = ?

A

These are OD levels

10-15 = Sz’s; unconsciousness

15-25 = apnea (pons & medullary depression); coma

S45

48
Q

A 50 y/o, 60 kg female patient received a Lidocaine initial dose of 1 mg/kg with a subsequent infusion of 1.5 mg/kg/hour for 1.5 hours. How much total Lidocaine in mgs did she receive in the PACU?

A

60kg x 1 mg/kg = 60 mg
60 kg x 1.5 mg/kg = 90 mg (1 hour)
(60 kg x 1.5mg/kg = 90 mg)/2 = 45 mg (30 minutes)

60+90+45 = 195 mg total!!!

CLASS question

49
Q

This med has anti-nociceptive effects by antagonizing the NMDA receptor and “probably” potentiates opioids centrally and peripherally.

A

Magnesium

S47

50
Q

Mg++ regulates which four cellular functions?

A
  • Ca++ access intracellularly.
  • Neurotransmission
  • Cell signaling
  • Enzyme function

S47

51
Q

Which ion has limited movement across the BBB?

A

Mg⁺⁺

S47

52
Q

What conditions are contraindicative for magnesium administration?

A

Myasthenia Gravis & Renal Failure

S47

53
Q

What is Mg⁺⁺ dosing for the following two situations?

Preop:
Intraop:

A
  • Preop: 50 mg/kg IV
  • Intraop: 8 mg/kg/hr IV

S48

54
Q

Which patients receive magnesium sulfate most often per Castillo?

A

Preeclamptic & eclamptic OB patients.

Slide 46

55
Q

What opioid requirement does the use of Mg++ significantly decrease?

A

Fentanyl

S48

56
Q

What adverse side effects could occur with Mg++?

A

- Hypotension
- bradycardia
* ataxia
* somnolence
* decreased muscular tone – check DTR

S48

57
Q

Evidence-based slide

What evidence based conclusion was found with the study “Perioperative systemic magnesium to minimize postoperative pain”?

A

a lot of these procedures used Fentanyl, Morphine PCA, Toradol, Tramadol and Meperadine as part of their pain pathway (not specific multimodal)

they did test for early and late pain at rest and movement

further findings: there is significant pain relief or pain control or reduction at intraop and post-op vs intraop only

also cited in their findings that there are opioid side effects of dizziness headache and post op nausea and vomiting

S49

58
Q

What is the MOA of Ondansetron and the use?

A
  • First 5-HT3 antagonist
  • Approved for CINV

S50

59
Q

Ondansetron is equivocal to what two drugs in its treatment of N/V?

A

Droperidol & Metoclopramide

60
Q

What are the side effects of Ondansetron?

S50

A
  • HA
  • Constipation
  • some QT prolongation

S50

61
Q

What is the dose of Ondansetron?

A

4 mg IV (up to 8 mgs)

Pediatrics: 0.1 mg/kg IV

S50

62
Q

What is the duration of Ondansetron?

A

plasma half life is 4 hours!

S50

63
Q

What is the MOA of Corticosteroids in the treatment of N/V?

A

MOA is unknown

It works on glucocorticoid receptors in Nucleus Tractus Solitarius (NTS).

S51

64
Q

Why are Corticosteroids used with 5-HT3 (Ondansetron) & Droperidol?

A

Increase effectiveness for 5 HT3 antagonists and Droperidol

S51

65
Q

What is the dose for Dexamethasone (Decadron)?

A

8 - 10 mg IV

S52

66
Q

What is the MOA of Dexamethasone (Decadron)?

A
  • Anti-inflammatory
  • inhibition of phospholipase and cytokines and stabilization of cellular membrane.

S52

67
Q

What is the delay of onset of Dexamethasone (Decadron)?

A

2 hours

S52

68
Q

What is the efficacy of Dexamethasone (Decadron)?

A

24 hours

S52

69
Q

Are there any adverse effects of a single dose of Dexamethasone (Decadron)?

What occurs if it is pushed fast?

A
  • Nope
  • Perineal burning/itching

S52

70
Q

According to the TXWES medication guide, what are the doses for Acetaminophen (Ofirmev), Ketorlac (Toradol), & Ibuprofen (Caldor).

A

Slide 60

KM (Spring 2024) COPY of Anesthesia Pharm (Spring 2023) (103 decks)

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