Pharm Flashcards
Exam II (220 cards)
1
Q
A drug that reversibly depresses the activity of the CNS
A
Sedative-Hypnotics
2
Q
A drug that reduces anxiety and that has sedation as a side effect
A
Anxiolytic
3
Q
What are Vessel-poor groups? What % of CO do they receive?
A
- Bone
- Tendon
- Cartilage; 2%
4
Q
Fat recieves how much CO?
A
5%
5
Q
What muscle groups receive how much CO? What %?
A
- Skeletal muscle
- Skin; 18%
6
Q
What are the vessel-rich groups? What % of CO do they receive?
A
- Brain
- Heart
- Kidney
- Liver ; 75%
7
Q
What are the 4 stages of general anesthesia?
A
- Analgesia
- Delirium
- Surgical Anesthesia
- Medullary Paralysis
8
Q
What are the 5 components of general anesthesia?
A
- Hypnosis
- Analgesia
- Muscle Relaxation
- Sympatholysis
- Amnesia
9
Q
It starts with the initiation of an anesthetic agent and ends with the loss of conciousness
A
Stage 1: Analgesia
10
Q
It starts with the loss of consciousness to the onset of automatic rhythmicity of vital signs.
A
Stage 2: Delirium
11
Q
It starts with the absence of response to surgical incision and depression in all elements of nervous system function.
A
Stage 3: Surgical Anesthesia
12
Q
It starts with cessation of spontaneous respiration and medullary cardiac reflexes.
A
Stage 4: Medullary Paralysis
13
Q
The lightest level of anesthesia
A
Stage 1: Analgesia
14
Q
Rapid stage that is chracterized by excitement, movements, laryngospasm, and emesis
A
Stage 2: Delirium
15
Q
Stage associated with flaccid paralysis, absent reflexes, and marked hypotension with a weak, irregular pulse
A
Stage 4: Medullary Paralysis
16
Q
What are the 4 induction drugs?
A
- Barbituates
- Propofol
- Etomidate
- Ketamine
17
Q
What drug is the gold standard for comparison with other drugs?
A
Barbituates
18
Q
What is the MoA of Barbituates?
A
Potentiate GABAA channel activity; directly mimics GABA
19
Q
What other receptors do barbituates work on besides GABAA?
A
- Glutamate
- Adenosine
- Neural nACh
20
Q
Barbiturates are cerebral vaso_____. They ______ CBF and ______ CRMO2 by 55%
A
vasoconstrictors; decrease; decrease
21
Q
Barbituates have a lengthy…
A
context-sensitive half-time
22
Q
Barbiturates have a ____ onset & _____ awakening d/t ____ uptake and ____ redistribution
A
rapid; rapid; rapid; rapid
23
Q
How are barbituates dosed?
A
Dosed on LEAN body weight
24
Q
What is the primary metabolism mechanism for barbituates?
A
Liver Hepatocytes
25
What drug is given rectally with uncooperative/young patients?
Barbituates
26
Which barbituates are the thiobarbituates?
1. Thiopental
2. Thiamylal
27
Which barbiturates are the oxybarbiturates?
1. Methohexital
2. Phenobarbital
3. Pentobarbital
28
What is the dose for Thiopental (Sodium Pentothal)? How is the dose calculated?
4 mg/kg IV; IBW
29
Describes the distribution of a given agent at equilibrium between two substances at the same temperature, pressure, and volume
Partition Coefficients
30
Describes the distribution of an anesthetic between blood and gas at the same partial pressure
Blood-gas coefficient
31
Which barbiturates have oxygen in the second position?
Oxybarbiturates
32
What gives thiobarbiturates more hypnotic potency and lipid solubility?
Sulfur atom in place of the oxygen atom in the second position.
33
What are two side effects of methohexital?
1. Myoclonus
2. Hiccoughs
34
What is the dose for Methohexital (Brevital)
1.5 mg/kg IV
35
What are the primary CV effects of barbiturates?
1. Lack of baroreceptor response
2. Histamine release - anaphylactoid response with previous exposure
3. Transient decreases in BP
4. Trainsent increase in HR
36
What are the primary respiratory effects of barbituates?
Dose-dependent depression of ventilatory centers
37
Results in immediate, intense vasoconstriction and excruciating pain that radiates along the distribution of the artery
Intra-arterial injection of barbiturates
38
What's the antidote for an intra-arterial injection of barbiturates?
Licodaine or papaverine
39
What is the MoA for propofol?
GABA receptor agonist
40
What's the induction dose for propofol?
1.5-2.5 mg/kg IV
41
What's the conscious sedation dose of propofol?
25-100 mcg/kg/min
42
What is the constitution of a 1% solution of propofol?
1. Soybean oil (10%)
2. Glycerol (2.25%)
3. Purified egg phosphatide (1.2%)
43
What are the 3 primary disadvantages of propofol?
1. Support bacterial growth
2. Causes increased plasma triglyceride concentrations
3. Pain on injection
44
What happens when propofol binds to a GABAA receptor?
Transmembrane chloride conductance increases
45
What is the elimination 1/2 time of propofol?
0.5-1.5 hours
46
A low lipid emulsion with no preservative and higher incidence of pain on injection.
Ampofol
47
What are 3 potential contraindications or precautions with propofol use?
1. Cirrhosis of the liver
2. Renal dysfunction
3. Pregnancy and the neonate
48
What are the two primary uses for propofol?
1. Induction
2. TIVA
49
Why do children require a higher dose of propofol?
Larger central distribution volume and faster clearance rate
50
1. Minimal analgesic and amnestic effects
2. Prompt recovery without residual sedation
3. Low incidence of PONV
4. Anticonvulsant
5. Bronchodilation
Benefits of propofol
51
What are two notable case types that benefit from propofol use?
1. Agent of choice in GI endoscopy procedures
2. Mechanically ventilated patients in the ICU or postop (cardiac, neuro, etc.)
52
What is the MoA for propofol's antiemetic effects?
It depresses subcortical pathways and has a direct depressant effect on the vomiting center
53
What's the sub-hypnotic dose of propofol? Anti-pruritic?
10-15 mg IV followed by 10mcg/kg/min; 10mg
54
What are the 3 primary CNS effects of propofol?
1. Decreases CRMO2, CBF, and ICP
2. Larger doses decrease CPP
3. Myoclonus
55
How does propofol cause its vasodilatory effects?
Inhibition of the SNS and decreases intracellular Ca2+
56
What does the green and cloudy urine from propofol come from?
1. Phenols (Green)
2. Uric acid crystallization (Cloudy)
57
What are two severe side effects of propofol?
1. Profound bradycardia and asystole in healthy adult patients
2. Severe, refractory, and fatal bradycardia in children
58
What causes pain at the injection site with etomidate?
Propylene glycol
59
What's the onset for Etomidate?
1 min
60
What's the dose for Etomidate?
0.3mg/kg
61
What's the MoA for Etomidate?
Selective modulator of GABAA receptors
62
What is the best patient population to use Etomidate with?
Patient's with unstable CV system
63
What are two of the primary side effects of Etomidate?
1. Myoclonus
2. Adrenocortical Suppression
64
How often does myoclonus happen in patients given Etomidate?
50-80%
65
What are two contraindications to using etomidate?
1. Sepsis
2. Hemorrhage
66
How is Etomidate metabolized?
Hydrolysis by hepatic microsomal enzymes and plasma esterases
67
What happens with adrenocortical suppression?
1. No stress response (no cortisol)
2. Enzyme inhibition for 4-8 hours
3. Severe hypotension
4. Longer mechanical ventilation
68
Fentanyl 50mcg/mL is available. Patient is 75kg. Administer 1mcg/kg to attenuate myoclonus. How many mLs will you administer?
1.5 mLs
69
What is ketamine a derivative of?
PCP
70
It resembles a cataleptic state in which eyes remain open with a slow nystagmic gaze. The patient is uncommunicative, but wakefulness is present. Purposeful movement.
Dissociative anesthesia
71
What is the preservative in ketamine?
Benzethonium Chloride
72
What is the MoA for Ketamine?
Inhibit uptake of catecholamines back into the postganglionic sympathetic nerve endings
73
What receptors to ketamine bind to?
N-Methyl-D-aspartate (NMDA) receptors
74
What is the most abundant excitatory neurotransmitter in CNS?
Glutamate
75
What are the pharmacokinetics of Ketamine?
1. Rapid onset
2. Short duration of action
3. Large Vd - highly lipid soluable
76
How long does ketamine last?
10-20 minutes
77
When is ketamine's peak plasma concentration?
1 minute
78
What is norketamine?
Active metabolite of Ketamine (1/3 potency)
79
What is the induction dose for ketamine?
0.5-1.5 mg/kg IV
80
What is the subanesthetic dose for Ketamine?
0.2-0.5 mg/kg IV
81
What induction drug has weak actions at GABAA receptors?
Ketamine
82
Besides NMDA, what are the other receptors that Ketamine works on?
1. Mu
2. Kappa
3. Delta
83
What are the neuraxial doses of Ketamine?
30 mgs Epidural
5-50 mg in 3mLs of saline intrathecal/spinal
84
Ketamine 25mgs/mL is available. How much diluent should be used to decrease the concentration to 5mgs/mL?
4 mLs
85
What is the coronary artery disease cocktail?
1. Diazepam 0.5mg/kg IV
2. Ketamine 0.5 mg/kg IV
3. Continuous ketamine infusion mcg/kg/min
86
What are some of the nonanesthesia clinical uses for ketamine?
1. Burn dressing, debridement, grafting
2. Psychiatric disorders
3. Reversal of opioid tolerance
87
What are the contraindications for ketamine?
1. PHTN
2. Increased ICP
88
What are some issues ketamine can cause during induction? How are they prevented/treated?
Coughing and laryngospasm; give an antisialoagogue or Glycopyrrolate
89
# With Ketamine ventilatory response to CO2is ___________ .
maintained/unchanged
90
Ketamine is a potent cerebral vaso________.
Vasodilator
91
What should be given 5 minutes before emergence in patients at risk for emergence delirium from ketamine?
Benzodiazepine
92
This induction agent has the highest analgesic properties.
Ketamine
93
Combining, admixing, diluting, pooling, reconsitutring, repackaging, or otherwise altering a drug or bulk drug substance to create a sterile preparation.
Sterile Compounding
94
The experience of pain with a series of complex neurophysiologic processes
Nociception
95
What are the two components of pain?
1. Sensory-discriminative - preception
2. Motivational-affective - response to pain
96
Increased pain sensations to normally painful stimuli
Hyperalgesia
97
Allodynia
Perception of pain sensations in response to normally non-painful stimuli
98
Nerve/electrical impulses/signals start at the nerve endings
Transduction
99
Travel of nerve/electrical impulses to the nerve body connecting to the the dorsal horn of the spinal cord.
Transmission
100
Process of altering (inhibitory/excitatory) pain transmission mechanisms at the dorsal horn to the PNS and CNS.
Modulation
101
Thalamus acting as the central relay station for incoming pain signals and the primary somatosensory coretex serving for discrimination of specfic stimuli
Preception
102
Where does the modulation of pain impulses occur?
Dorsal Horn
103
Chemical Mediators
PELNCCE
1. Peptides (Substance P, Calcitonin, Bradykinin, CGRP)
2. Eicosanoids
3. Lipids (Prostaglandins, Thromboxanes, Leukotrienes, Endocannabinoids)
4. Neutrophils
5. Cytokines
6. Chemokines
7. Extracellular proteases and protons
104
At the original site of injury from heat and mechanical injury
Primary Hyperalgesia
105
Pain sensation from uninjured skin surrounding the actual injury (only from mechanical stimuli)
Secondary hyperalgesia
106
Pain is not felt with simultaneous inhibitory impulses
Gate Closed
| A beta fibers
107
Pain is projected to supraspinal brain regions
Gate open
| A delta & C fibers
108
Which lamina is the substantia gelatinosa? What affects this pathway?
Lamina II; Opiates and afferent C-fibers
109
Which lamina is the marginal layer? Which fibers use this pathway?
Lamina I; C-fibers
110
What lamina has the NKI receptor? What activates this receptor?
Lamina III & IV; Substance P
111
What structures depress or facilitate the integration of pain info in the spinal dorsal horn?
Periaqueductal gray-rostral ventromedial medulla (PAG-RVM)
112
What are the 5 excitatory impulses?
| GCNAS
1. Glutamate
2. Calcitonin
3. Neuropeptide Y
4. Aspartate
5. Substance P
113
What are the 5 inhibitory impulses?
| GGEND
1. GABA
2. Glycine
3. Enkephalins
4. Norepinephrine
5. Dopamine
114
What are the two descending pathways of pain modulation?
1. Descending inhibition pathway
2. Descending facilitation pathway
115
What are the 4 ascending pathways of nociceptive information?
1. Spinothalamic - pain, temp, itch
2. Spinomedullary
3. Spinobulbar
4. Spinohypothalamic - autonomic
116
When do neonates start to feel pain?
23 weeks of gestation
117
What are the receptors for the PAG-RVM system?
μ, κ, δ
118
What type of pain persists after the tissue has healed? Cancer patients have an increased risk for this type of pain.
Neuropathic
| Will also see allodynia and hyperalgesia with this type pain.
119
What is the GI response to pain?
N/V
120
What are the emotional responses to pain?
1. Anxiety
2. Sleep disturbance
3. Depression
121
What are the immune responses to pain?
1. Leukocytosis- stress related
2. Depressed reticuloendothelial system - increased infection
122
What are the 4 advantages of opioid agonist-antagonists?
1. Analgesia
2. Limited ventilation depression
3. Low potential for physical dependence
4. Ceiling effect prevents additional responses
123
When are opiod agnists-antagonists used?
When a patient is unable to tolerate a pure agonist
124
What is the MoA for opioid agonists-antagonists?
1. μ - partial (agonist) or no effect (competitive antagonist)
2. κ, δ - partial effect (agonist)
125
Which opiod agonist-antagonist has withdrawal as a side effect?
Burenorphine
126
Which opioid agonist-antagonist is used with cardiac catheterization patients?
Nalbuphine
127
Which opioid agonist-antagonist has effects on the κ, δ receptors with weak antagonist activity and excretion via glucoronide conjugates?
Pentazocine
128
Pentazocine
Butorphanol
Nalbuphrine
Buprenorphine
Nalorphine
Bremazocine
Dezocine
are all examples of what type of opioids?
Opioid agonists-antagonists
129
Which opioid agonist-antagonist is more potent than morphine?
Buprenorphine
130
Which opioid agonist-antagonist has affinity for all three opioid receptors?
Butorphanol
δ - minimal affinity
μ - low affinity
κ - moderate affinity
131
What are the 3 opioid antagonists?
Naloxone
Naltrexone
Nalmefene
132
What are two other uses for Naloxone?
1. Neonate
2. Antagonism of general anesthesia at high doses
133
How long does Naloxone last?
30 to 45 minutes
134
What is the MoA of opioid antagonists?
Pure μ opioid receptor competitive antagonists with no agonist activity.
135
Name three S/E of Naloxone.
1. Reversal of analgesia (not a side effect...)
2. N/V
3. Increased SNS (HR, BP, pulmonary edema, arrythmias)
136
What kind of medications are suboxone, Embeda, and OxyNal?
Tamper or abuse resistant opioids
1. Suboxone (buprenorphine + naloxone)
2. Emebda (ER morphine + naltrexone)
3. OxyNal (oxycodone + naltrexone)
137
What medication decreases MAC? How much of a decrease?
Fentanyl; decreases MAC of Iso and Des by 50%
138
What structure/pathway in the spinal cord contains opioid receptors?
Substantia Gelatinosa
139
What are the neuraxial routes for opioids?
1. Epidural
2. Spinal
3. Intrathecal
4. Subarachnoid
140
What does adding epinephrine to epidurals help prevent?
Venous plexus injuries
141
What are the peak concentrations in epidurals for Fent, Sufent, and Morphine?
Sufent - 6 minutes
Fent - 20 mimnutes
Morphine - 1-4 hours
142
What causes itching with neuraxial opioids?
Cephalad (head or anterior end of the body) migration of the opioid to trigeminal nucleus
143
What determines cephalad movement of opioids in the CSF?
Lipid solubility
144
Which drug is used to attenuate the side effects of neuraxial opiods?
Naloxone
145
Which opiates are phenanthrenes?
1. Morphine
2. Codeine
3. Thebaine
146
Greek word stupor, which has the potential to produce physical dependence
Narcotic
147
All exogenous substances (natural & synthetic)
Opioid
148
In addition to opiate receptors, where else do opiates have an effect?
Pre & postsynaptic sites in the CNS
149
Opiates have ____synaptic inhibition of what substances?
pre; ACh, dopa, NE, Substance P
150
Where are the opioid receptors in the brain?
1. Periaqueductal gray (PAG)
2. Locus ceruleus
3. rostral ventral medulla (RVM)
4. Hypothalamus
151
Where are the opioid receptors in the spinal cord?
Interneurons and primary afferent neurons in the dorsal horn (substantia gelatinosa)
152
Where are the opioid receptors outside of the CNS?
sensory neurons and immune cells
153
What is the CV benefit of opioids?
cardioprotective from myocardial ischemia
154
What is the primary CV side effect of opioids?
Decreased SNS tone in peripheral veins (decreases VR, CO, & BP, orthostatic hypotension & syncope), bradycardia
155
Which medication increases CNS levels of ACh and antagonizes ventilatory depression, but not analgesia?
Physostigmine
156
What is the MoA for decreased ventilation with opiates?
1. Activation of Mu2 receptors which decrease ventilation rate with a compensatory increase in tidal volume
2. Increased in resting PaCO2
157
What are symptoms of opioid overdose?
Hypoventilation, miosis apnea, & coma
158
What's a contraindication for opiates?
Head injury
159
What are 3 CNS side effects of opioids?
1. Myoclonus with large doses
2. Thoracic and abdominal muscle rigidity
3. Decreased CBF and possibly ICP
160
What 3 opiates cause spasm of biliary smooth muscle or sphincter of Oddi spasms?
1. Fentantyl
2. Morphine
3. Meperidine
161
What medication is given for patients with biliary smooth muscle spasms?
Glucagon (2 mgs IV - given incrementally)
162
What is the primary GI side effect of opioids?
Delayed gastic emptying and constipation
163
What are the initial symptoms of opioid withdrawal?
Yawning, diaphoresis, lacrimation, insomnia, restlessness, coryza
164
What is the onset time for fentanyl, sufentantil, and remifentantil?
30-60 seconds
165
What are the two metabolites of morphone?
1. Morphine-3-glucuronide (inactive)
2. Morphine-6-glucuronide (active)
166
What type of pain is morphine best at?
dull pain
167
What is the normal dose for morphine?
1-10mg IV
168
What is the normal onset for morphine?
10-20 minutes
169
What is the peak time for morphine?
15-30 minutes
170
Which morphine metabolite has a longer elimination 1/2 time?
Morphine-3-Glucuronide
*caution with renal dysfunction*
171
Which receptors does meperidine work on?
Mu and kappa
172
What are the 4 analogues of mepridine?
1. Fentanyl
2. Sufentanil
3. Alfentanil
4. Remifentanil
173
What's the dose for post-op shivering with meperidine?
12.5 mgs
174
What is the duration of meperidine? What is the elimiation 1/2 time?
2 to 4 hours; 3 to 5 hours
175
What is the induction dose of fentantyl?
1.5 to 3 mcg/kg IV
176
What is the analgesic dose of Fentanyl
1-2 mcg/kg IV
177
What's the induction dose of remifentanil?
0.5 to 1 mcg/kg IV over 30-60 seconds
178
What is the maintainence dose of remifentanil?
0.005 to 2 mcg/kg/min
179
What can using alfentanil with alzheimer patients cause?
acute dystonia
180
What is the dose of hydromorphone?
0.5 mg IV (1 to 4 mgs total)
181
What is the cough suppressant dose of coedine?
15 mgs
182
What receptors does tramadol work on?
Mu, weak kappa, and delta.
183
What's the chemical ring in most opioids?
Piperdine
184
What is the dose for super mag?
400 mg
185
What is the dose for IV tylenol?
1000mg q4-6 hours.
186
What is the intraop dosage for ibuprofen?
200-800 mg IV over 30 minutes Q6h
187
What are the chronic pain syndromes gabapentin can be used for?
1. Diabetic neuropathy
2. Post-herpetic neuralgia
3. Reflex sympathetic dystrophy
4. Phatom limb pain
5. Fibromyalgia
188
What are the two primary indications for gabapentin?
1. Partial seizures in adults/children
2. chronic pain syndromes
189
What's the MoA for gabapentin?
1. Binds VG-Ca2+channels
2. Enhances descending inhibition
3. Inhibits excitatory NT release
190
What's the dose for gabapentin?
300-1200mg PO 1-2 hours prior to OR
191
When is Gabapentin contraindiciated?
1. MG
2. Myoclonus
| Reduce dose in elderly.
192
What are some of the benefits of NSAIDs?
1. Long duration of action
2. Prepemptive analgesia
3. Less N/V
4. Abscense of cognitive effects
5. No addictive potential
6. No respiratory depression
193
What do NSAIDs do?
1. Analgesic (Decrease activation of peripheral nociceptors)
2. Antiinflamatory
3. Antipyretic
194
What medications are the nonspecific NSAIDs?
1. Ibuprofen
2. Naproxen
3. Aspirin
4. Acetaminophen
5. Ketorolac
195
What are the COX-2 Selective NSAIDs?
1. Celecoxib (Celebrex)
2. Rofecoxib (Vioxx)
3. Valdecoxib (Bextra)
4. Parecoxib (Dynastat)
196
What's the dose for Celebrex?
200 to 400mg PO QD
197
What is the enzyme that catalyzes synthesis of PG?
Cyclooyxgenase
198
Ubiquitous, "physiologic", "Constituative"
COX-1
199
"Inducible", "pathophysiologic", sensitization
COX-2
200
What's the dose for ketorolac?
15-30mg q6hr
| 1/2 dose in elderly
201
What is the peak for IV tylenol?
30 minutes to 1 hour
202
What is the TEAM health forumla for Ketamine?
1. 0.25 to 0.5 mg/kg pre incision
2. 0.25 to 0.5 mg/kg intraop
3. Stop 1 hour prior to surgery end
4. 0.12 mg/kg/hr for 24 hours postop
| or 5mg boluses between 0.3 to 0.5 mg/kg/hr
203
What's the dose for lidocaine?
1-2 mg/kg IV over 2-4 minutes
204
What's the TEAM health dose for Lidocaine?
1. 1.5 mg/kg at induction
2. 1-2 mg/kg/hr for 24 to 48 hours post-op
205
What dose of lidocaine corresponds to analgesia?
1-5 mcg/mL
206
What dose of lidocaine corresponds to tinnitus, muscle twitching, hypotension, myocardial depression, and oral numbness
5-10 mcg/mL
207
What dose of lidocaine corresonds to seizures and unconciousness?
10-15 mcg / mL
208
What dose of lidocaine corresponse to apnea and coma?
15-25 mcg/mL
209
What dose of lidocaine corresponds to cardiovascular depression?
> 25 mcg/mL
210
What is the primary contraindication for Ketorolac (Toradol)?
Severe renal impairment
211
What's the peak time for celebrex?
3 hours
212
What's the team health dose of Mg2+
30 to 50 mg/kg IV loading dose
Continue 8 to 10 mg/kg/hr
213
What's the preop dose for Mg2+
50 mg/kg IV
214
What decreases ondansetron effectiveness?
Variations in CYP2D6 activity
215
What's the dose for ondansetron?
4 mg to 8mg IV
216
What's the dose for pediatric ondansetron?
0.1 mg/kg IV
217
What medications do corticosteroids increase the effectiveness of?
Increases effectiveness for 5-HT3 antagonists and droperidol
218
What is the dose for decadron?
8 to 10 mgs?
219
What endogenous substances are peptides?
| SCBC
Substance P, Calcitonin, Bradykinin, and CGRP
220
What endogenous substances are lipids?
| PTLE
Prostaglandins, Thromboxanes, Leukotrienes, and Endocannabinoids
