More Block 2 Flashcards by Markus M

BZD MOA?

Activates GABAa receptors

Increases Cl influx

No analgesic affect

How well did you know this?

Not at all

Perfectly

Diazepam
Lorazepam
Midazolam

Which one has the shortest and longest t1/2?

Midazolam = shortest (2hrs)

Diazepam = longest (up to 55hrs)

How well did you know this?

Not at all

Perfectly

BZD AE (especially w/ opioids)?

Respiratory depression

How well did you know this?

Not at all

Perfectly

Propofol MOA?

Activates GABAa receptors

Increases Cl influx

No analgesic affect, but induces anesthesia + an antiemetic

How well did you know this?

Not at all

Perfectly

Propofol formulation info?

Not an antimicrobial preserved product (must have strict aseptic technique when handling)

Reported to have injection site pain and hyperlipidemia

Stored at 4-25C, no freezing

Water INsoluble

How well did you know this?

Not at all

Perfectly

Propofol PK info?

Zero oral bioavailability

Elimination is unchanged if you have liver/kidney damage

How well did you know this?

Not at all

Perfectly

Propofol AE?

Respiratory depression (needs monitoring!)

Hypotension (dose-dependent vasodilation)

Bradycardia, reduction in heart contractility

Propofol Infusion Syndrome (PRIS) – rare but potentially fatal

How well did you know this?

Not at all

Perfectly

Fospropofol metabolism?

Metabolized by alkaline phosphatase

How well did you know this?

Not at all

Perfectly

Fospropofol formulation and AE?

Minimal injection site pain and hyperlipidemia

Water Soluble

Less frequent of respiratory depression or hypotension

How well did you know this?

Not at all

Perfectly

Ketamine MOA?

NMDA antagonist

How well did you know this?

Not at all

Perfectly

Ketamine use?

For analgesia (supposedly no respiratory depression)

Hallucinations + Date rape drug

How well did you know this?

Not at all

Perfectly

Ketamine PK?

Typically given as IV, IM is too painful

How well did you know this?

Not at all

Perfectly

Ketamine AE?

Emergence reactions

Transient increase in BP, HR, CO

How well did you know this?

Not at all

Perfectly

Precedex MOA?

Alpha 2 agonist

Locus coeruleus – activates sleep pathways

Spinal cord – analgesia

How well did you know this?

Not at all

Perfectly

Precedex AE?

Hypotension/hypertension

Bradycardia

Does NOT cause respiratory depression

How well did you know this?

Not at all

Perfectly

How is skeletal muscle initiated?

Action potential causes depolarization of calcium channel

Calcium channel opens and influx of calcium releases ACh

ACh binds to ACh nicotinic receptor

Sodium enters the muscle cell and ACh is degraded by AChE

How well did you know this?

Not at all

Perfectly

General paralytic MOA?

Blocks ACh from binding to ACh nicotinic receptor

How well did you know this?

Not at all

Perfectly

What is the only depolarizing paralytic?

Succinylcholine

Everything else is competitive/non-depolarizing (roc, vec, nimbex)

How well did you know this?

Not at all

Perfectly

Competitive/non-depolarizing paralytic MOA?

Blocks ACh from binding to receptor however the effect can be overcome by excessive ACh like AChE inhibitors unless there is a high dose of this paralytic, then excessive ACh cant overcome it

How well did you know this?

Not at all

Perfectly

How does paralysis occur based on susceptibility?

First: face, eye
Then: fingers, limbs, neck, trunk
Last: Intercostal muscle, diaphragm

How well did you know this?

Not at all

Perfectly

PK info on competitive/non-depolarizing paralytics?

Zero oral bioavailability + cant cross BBB

How well did you know this?

Not at all

Perfectly

Roc
Vec
Pancuronium
Nimbex

Metabolism info?

Roc + Vec = deacetylated in liver, no excreted into bile unchanged

Pancuronium = excreted unchanged in urine

Nimbex = degraded by plasma and ester hydrolysis

How well did you know this?

Not at all

Perfectly

Succinylcholine MOA?

Drug causes membrane depolarization but AChE cant hydrolyze it and causes fasciculations

After a prolonged time,
Phase I - Depolarizing = flaccid paralysis (can be augmented by AChE inhibitors

Phase II - slowly converts to this phase of non-depolarization

How well did you know this?

Not at all

Perfectly

Succinylcholine AE?

Soreness, hyperthermia, hyperkalemia, apnea

How well did you know this?

Not at all

Perfectly

What does the BPS pain scale look at? CPOT

Facial expression Upper limbs Ventilation compliance Scores from 3-12, intervene when score is ≥6 CPOT adds vocalization, muscle tension instead of upper limbs, body movement CPOT ≥2 is significant

Fentanyl Hydromorphone Morphine If you have liver issues, what are the better options?

Hydromorphone + Morphine

Treatment options for neuropathic pain?

Gabapentin Carbamazepine Pregabalin

What are some misc. treatment options that are never recommended for pain + ICU?

Lidocaine >1 dose NSAID

What does the RASS score tell you?

Ranges from -4 to +5 Negative = sedated Positive = agitated

Diazepam Lorazepam Midazolam If you have liver issues, which one should you choose?

Lorazepam

Diazepam Lorazepam Midazolam Which one is associated with propylene glycol toxicity?

Lorazepam

What did the Awake and Breathing Controlled trial show us?

Taking ppl off sedation and having them breathe on their own and placing them back on 1/2 dose sedation improve ICU stay

What is the CAM-ICU assessment used for?

Delirium Looks at: Mental status change Inattention Altered consciousness or disorganized thinking ICDSC is also used

How do you treat delirium?

Prevention is #1 Haldol might work Quetiapine might work too Use both in short term

Because paralytics dont just target nicotinic receptors, they also target muscarinic receptors which are M1, 2, and 3. What organs are affected and what AE are expected?

M1 (Increased IP3) = CNS + parietal cells, CNS excitation + increased gastric acid secretion M2 (decreased cAMP) = Heart, decreased rate, force, and AV conduction M3 (Increased IP3) = smooth muscles + exocrine glands; smooth muscle contraction except vasodilation and glandular secretion

Roc Vec Pancuronium Nimbex Which one is associated with increased risk of tachycardia?

Pancuronium

Roc Vec Pancuronium Nimbex Which one is associated with increased risk of hypotension?

None; its atracurium

ICU acquired muscle weakness is typically associated with both paralytics and ______

steroids

Which paralytic should be used for these conditions? Acute respiratory distress syndrome (ARDS)\ Status asthmaticus Targeted temperature management Elevated intracranial pressure

ARDS - Nimbex Status asthmaticus - none, should be the absolute last thing you should try Temp management - no recommendation for hypothermia following cardiac arrest, but for therapeutic hypothermia, but you could use any; you want to prevent body from shivering to use less O2 Elevated ICP - can only be used if deep sedation is used and insufficient, same MOA as temp management

``` Succinylcholine Roc Vecuronium Pancuronium Nimbex ``` Which one doesnt involve in renal/liver issues when eliminating rx?

Succ + Nimbex (#1) Succ via pseudocholinesterase hydrolysis Nimbex via Hoffman elimination and ester hydrolysis

If pt requires a paralytic and nimbex is out, what are the next few drugs you could use?

Next up is roc, then vec, then lastly pancuronium

What are some medications that can enhance the blockade of paralytics?

Abx CV drugs Steroids Anesthetics

Which conditions can enhance the blockade of paralytics?

Low calcium, sodium, potassium High magnesium Acidosis

What are some medications that can decrease the blockade of paralytics?

Anticonvulsants Methylxanthine Ranitidine

Which conditions can decrease the blockade of paralytics?

High calcium Alkalosis

Nimbex bolus + continuous dosing?

Bolus = 0.1-0.2mg/kg Continuous = 3mcg/kg/min initially, then 1-2mcg/kg/min

Before giving a dose of paralytics, what should you give the patients first?

Sedation + analgesia

How do you monitor for the effects of NMDAs?

1. Clinical assessment | 2. Peripheral nerve stimulation (TOF)

What is the Train-of-four assessment?

4 pulses to deplete ACh Goal = 1-2 out of 4 twitches T4/T1; if its ≥0.9 it means they can breath on their own and are probably not paralyzed But dont rely on this assessment alone, use synchrony and oxygen consumption to guide therapy

How do you reverse paralytics?

For NON-DEPOLARIZING agents only: Neostigmine Pyridostigmine Bridion** **Roc or Vec only

Whats typically given with neostigmine/pyridostigmine due to excess levels of ACh?

To prevent muscarinic effects, give glycopyrrolate or atropine Bridion doesnt have these muscarinic effects

Succinylcholine AE?

Bradycardia

Succinylcholine dosing considerations

Increase dose in myasthenia gravis Dont give w/ h/o of malignant hyperthermia Avoid in children Raises potassium by 0.5

What do you use to treat malignant hyperthermia?

Dantrolene; reduces calcium release

Etomidate Ketamine Propofol BZD Which one can you give in septic shock?

Ketamine + BZD

Etomidate Ketamine Propofol BZD Which one can you give in status asthmaticus?

Ketamine + Propofol

Etomidate Ketamine Propofol BZD Which one should someone w/ soy allergy avoid?

Propofol

Etomidate Ketamine Propofol BZD Which one causes decreased BP and bradycardia?

Propofol

Etomidate Ketamine Propofol BZD Which one should be avoided in TBI or MI?

Ketamine

Etomidate Ketamine Propofol BZD Which one causes a potential of transient adrenal suppression for 48hrs?

Etomidate

Etomidate Ketamine Propofol BZD Which one can you give in seizures?

BZD

Etomidate Ketamine Propofol BZD Which one should NOT be used in septic shock?

Etomidate + Propofol

Etomidate Ketamine Propofol BZD Which one should NOT be used in bradycardia?

Propofol

What are the pretreatment options for patients before paralytics?

LOAD, M Lidocaine; suppresses cough, sodium channel, an amide (allergy), metabolized by liver Opioids Atropine; potentially used for pediatrics Defasciculating paralytic Low dose midazolam