Pharm Flashcards
(176 cards)
1
Q
What inhaled gas provides analgesia?
A
NO
all the others such as Sevo do NOT provide analgesia
2
Q
T/F: The exact MOA of inhaled anesthetics is known/agreed upon
A
False
Inhaled anesthetics produce immobility via actions on the spinal cord [Campagna JA et al. N Engl J Med 348: 2110, 2003]. There is consensus that inhaled anesthetics produce anesthesia by enhancing inhibitory channels and attenuating excitatory channels, but whether or not this occurs through direct binding or membrane alterations is not known. [Miller]
3
Q
At what MAC do 95% of patients not respond to surgical incision?
A
1.2 MAC
4
Q
At what MAC do 99% of patients not respond to surgical incision?
A
1.3 MAC
5
Q
How much MAC of Sevoflurane would you use if your goal was 1.4 MAC and you planned to concurrently administer 0.5 MAC of NO?
A
0.9 MAC of Sevo
According to “rat” data, MAC values are additive in terms of preventing movement to incision (0.5 MAC of nitrous oxide plus 0.5 MAC of isoflurane = 1.0 MAC of any other agent)
6
Q
What color is associated with: Sevo, Des and Iso?
A
Des = Blue
Sevo = Yellow
Iso = Purple
7
Q
What volatile anesthetic would be a good choice for rapid emergence for an obese patient?
A
Desflurane - because it has very low solubility it can be absorbed quickly and eliminated quickly
8
Q
What VA can cause emergence delirium in kids?
A
Sevo
9
Q
What VA is very lipid soluble, causing a longer emergence?
A
Iso
10
Q
What factors increase anesthetic requirements?
A
Chronic ETOH, infant, red hair, hypernatremia and hyperthermia
11
Q
At what age is MAC requirement the highest?
A
6 months
12
Q
What factors decrease anesthetic requirements?
A
Acute ETOH, elderly, hyponatremia, hypothermia, anemia (generally Hgb less than 5), hypercarbia, hypoxia and pregnancy
13
Q
What is the relationship of acute vs chronic ETOH in MAC requirements?
A
Chronic ETOH increases requirements, acute ETOH decreases it
14
Q
Your mental trick to identifying what factors increase/decrease MAC requirements?
A
If it is something that makes the system more excitable (like hyperthermia/hypernatremia) you likely need more anesthetic, if it is something that decreases excitability (acute ETOH - you are already drowsy/altered, hypo-natremia/thermia) or reduces how much blood goes to the head (pregnancy)
15
Q
Why does anesthetic gas require very small/careful titrations?
A
They are very potent with a very narrow TI/therapeutic window
16
Q
T/F: VA experience little to no metabolism
A
True
17
Q
Why is measurement of expired VAs important?
A
Because what we expire mimics what is in the brain at that given moment
18
Q
1% solution is what concentration?
A
10 mg/ml
19
Q
0.25% solution is what concentration?
A
2.5 mg/ml
20
Q
1:200,000 is what concentration?
A
5 mcg/ml
21
Q
1:10,000 is what concentration?
A
0.1 mg/ml
This is your standard epi concentration in the code cart
22
Q
List the induction, sedation and TIVA doses for propofol
A
Induction = 2 mg/kg IV
Sedation = 25 – 100 mcg/kg/min
TIVA = 100 – 300 mcg/kg/min
23
Q
T/F: propofol is a controlled substance
A
False
24
Q
What conditions does the propofol dose need to be changed: elderly, AKI, or liver failure?
A
Elderly - Propofol dose rarely needs to be changed with renal/liver disease
25
What induction agent is a good choice for asthma patients?
Propofol - acts as a bronchodilator
*ketamine is also a very potent bronchodilator*
26
What IV agent is the best choice to suppress the SNS response to DL?
Propofol
27
Describe propofol infusion syndrome
Sudden onset of bradycardia that progresses to
asystole and is resistant to treatment.
*No antidote; expect the need for high dose pressors/inotropes*
28
What induction agent requires GABA to be present in order to work?
Etomidate (it is a GABA modulator, it does NOT mimic GABA)
29
When is the imidazole ring water soluble? Lipid soluble?
Water = open ring
Lipid = closed ring
30
What is the standard concentration of etomidate?
0.2% or 2 mg/ml
31
What is the primary indication for etomidate? Contraindication?
Indication = CV instability
Contra = history of seizure or seizure risk, also adrenal insufficiency
32
Induction dose of etomidate?
0.3 mg/kg IV
*Of note, earlier pharmacology lectures gave a range of 0.2 - 0.4 mg/kg IV*
33
What induction agent has the highest incidence rate of PONV?
Etomidate (up to 30%)
34
T/F: Ketamine is a hypnotic
False: it causes dissociative anesthesia by providing profound analgesia and amnesia, but not hypnosis
35
What is the most common concentration of ketamine?
5% or 50 mg/ml
36
What is the induction dose of ketamine?
1.5 mg/kg IV
37
What is the intense analgesia dose of ketamine?
0.2 - 0.5 mg/kg
38
What is the "calm the kid" dose of ketamine?
4 - 8 mg/kg IM
39
What medications make up the "ketamine dart" to calm a child?
Ketamine, versed and robinol (other anti-cholinergic like atropine may be used)
40
Primary contraindication to ketamine?
If the patient is on a MAOI - can greatly increase circulating epi
41
Co-administration of what can help manage/reduce hallucinations when using ketamine?
Vitamin V! Or the lame version: Versed
42
T/F: the airway is considered protected with ketamine administration
False: it causes little direct respiratory depression (and keeps the laryngeal/pharyngeal reflexes intact), but because of the dissociation the airway is NOT considered fully protected
43
What are the 3 different a2 receptor subclasses (include their primary function)?
α2A: Sedation, Hypnosis, Sympatholysis
α2B: Vasoconstriction, Anti-shivering, Analgesia, Ca linked– may be excitatory
α2C: Learning, Startle response
44
Standard concentration and preparation of precedex?
0.1 mg (100 mcg) per ml in a 2 ml vial, mix with 48 cc of NS to get a working concentration of 4 mcg/ml
45
What is the loading dose and infusion rate of precedex?
lD = 1 mcg/kg over 10 minutes (too fast may cause HTN)
Infusion = 0.2 - 0.7 mcg/kg/hr
46
What induction/maintenance agent has an anti-sialagogue effect?
Precedex
47
Why is precedex so useful for drug/ETOH addicts?
It offsets withdrawal symptoms well
*ETOH withdrawal under anesthesia has extremely high mortality rate*
48
What induction agent widens thermo-regulation (think anti-shivering) and decreases muscle rigidity?
Precedex
49
What is the standard concentration of Methohexital (Brevital)?
1 - 2% or 10 - 20 mg/ml
50
What is the adult dose of Methohexital (Brevital)?
1.5 mg/kg
51
Why is giving the correct dose of Methohexital (Brevital) so crucial?
High doses can treat seizures, whereas low doses can encourage an epileptogenic state and cause myoclonus and hiccups
52
What is the primary use of Methohexital (Brevital)?
For rapid non-painful procedures such as: ECTs (good because it doesn't depress the seizure), cardioversion and mapping seizure focus
53
Standard post-op pain dose of morphine?
5 - 20 mg
54
What is the primary concern with intrathecal morphine use?
Delayed respiratory depression
55
Why is Dilaudid preferred over morphine?
It has less histamine release
56
Do you dose fentanyl of IBW or TBW?
IBW
57
What is the dose of fentanyl for the 1st hour of surgery?
1 - 5 mcg/kg
58
What is the infusion rate of fentanyl? When do you DC it?
3 - 6 mcg/kg/hr, turn off at least 60 minutes prior to need for patient to breath independently
59
Primary use for Demerol?
To treat shivering
60
Standard dose of Demerol?
12.5 mg IV
61
What does Demerol structurally mimic?
Atropine and LAs
62
What is the concern with Demerol's active metabolite?
CNS stimulant = seizure risk
63
What is the dose of Sufentanil?
0.5 - 1 mcg/kg
64
Infusion dose of Sufentanil? When do you DC?
0.5 - 1 mcg/kg/hr
DC 30 minutes prior to breathing if the infusion has been running less than 2 hours, DC 45 minutes prior if the infusion has been going greater than 2 hours
65
Primary advantages of sufentanil?
CV stable and better post-op pain control than Remi because it sticks around longer
66
Standard concentration of sufentanil?
50 mcg/ml
67
What is the loading dose and infusion of Remi?
LD: 0.5 - 1 mcg over 1 minute
Infusion: 0.125 - 0.375 mcg/kg/min (turn off 6 min prior to breathing)
68
What narcotic is primarily metabolized by plasma esterases?
Remi
69
How much can Remi reduce MAC?
Up to 70% reduction
70
Primary uses for Remi?
Neuro cases (fast on/off), carotid endarterectomy, eye blocks, TIVA
71
What intervention must be done with stopping a Remi infusion?
Must cover post-op pain with another drug as Remi wears off so quickly
72
In what field/branch of anesthesia are you most likely to use partial agonist/antagonist narcotics?
OB
73
What class of drugs can treat pruritis without reversing analgesia?
Partial agonist/antagonist narcotics
74
Standard dose to treat respiratory depression with narcan?
40 - 80 mcg IV
75
What is the standard concentration of narcan?
400 mcg/ml
76
If you want to give 80 mcg of narcan in 2 ml, how would dilute it down from its standard concentration?
SC = 400 mcg/ml, there are a few options here, but the easiest way is to keep the numbers simple. Add 9 ml, so you have 400 mcg / 10 ml or 40 mcg / ml, draw up 2 ml and now you have 80 mcg in 2 ml
77
What is the rare but emergency condition associated with narcan?
Flash pulmonary edema
78
What are the 5 primary effects of BZDs?
Sedation.
Anxiolysis.
Hypnotic.
Anticonvulsant.
Spinal cord – mediated skeletal muscle relaxation
79
List the primary BZDs we use in order of increasing potency?
Diazepam -> Midazolam -> Lorazepam
*Ativan is x5 more potent than versed, and versed is x5 more potent than valium*
80
Why are BZDs discouraged for patients with chronic COPD, OSA and/or obesity?
BZDs depress the hypoxic drive to breathe, which is what the 3 listed conditions use to breathe, so a BZD could seriously depress their drive to breathe
81
T/F: BZDs blunt the SNS response to DL and intubation?
False
82
Why is PO ativan/valium a good choice for anxiolysis in someone with COPD, OSA or obesity (assuming you MUST give a BZD in this scenario)?
The PO route has almost no respiratory depression when used alone
83
What is the standard dose of Flumazenil?
0.2 mg IV
84
What is the standard concentration of Flumazenil?
0.1 mg/ml or 0.01%
85
What is the max dose of Flumazenil?
3 mg total; you can repeat doses of 0.1 mg IV q1m with a max of 1 mg per hour and total max of 3 mg
86
Name the drug: (Anti nausea, anti inflammatory, long acting)
Decadron
87
Name the drug: Very safe (watch for QT), difficult to overdose, very effective
Zofran
88
Name the drug: Tough to find anymore, Watch QT, can cause sedation/confusion
Droperidol
89
Name the drug: … Forward motility, works on dopamine receptor, can cause anxiety, extrapyramidal side effects. Got a bad rap because of flawed studies.
Reglan
90
Name the drug: Antihistamine, Histamine receptors are in the chemoreceptor trigger zone
Benadryl
91
Name the drug: Very effective for those with motion sickness, multi day treatment, remember education for removal.
Scop patch
92
Name the drug: H2 blocker, decreases acid, but can reduce N/V, FDA approved for morning sickness
Pepcid
93
Name the drug: Usually a rescue drug, sedation qualities, MUST dilute and make certain IV is working, extravasation can result in loss of limb. IV or IM use only
Phenergan
94
Name the drug: Has anti-emetic properties, can be used as a last ditch rescue, can also be used in TIVA, avoiding gas to reduce N/V in high risk patients.
Propofol
95
Name the drug: Newer, expensive drug, for use in very high risk patients. A substance P/nk-1 antagonist (also a CTZ trigger). A previously unexplored pathway to prevent N/V
Aprepitant
96
What paralytic is essentially just 2 Ach molecules bound together?
Sux
97
Sux is antagonized by what? Augmented by what?
Antagonized = non-depolarizers
Augmented = acetylcholinesterase
98
What are the primary advantages of Nimbex?
No histamine release, dose doesn't change with illness or age and does not accumulate
99
What is the infusion rate of Nimbex?
1 - 2 mcg/kg/min
100
Standard concentration of Nimbex?
2 mg / ml or 0.2%
101
What is the paralytic of choice in renal failure?
Nimbex - because it is metabolized by plasma cholinesterase's rather than an organ
102
What paralytic is a monoquateranary aminosteroid?
Vecuronium (norcuron)
103
What is the infusion rate of Vec?
1 - 2 mcg/kg/min
104
What organ primarily metabolizes Vec?
Liver
105
Intubating dose of Vec?
0.1 - 0.2 mg/kg
106
Standard concentration of Roc?
10 mg/ml or 1%
107
What conditions can prolongate the effect of Roc?
Liver failure (moderate) elderly/pregnant (slight)
108
Standard induction dose of Roc? RSI dose?
SI = 0.6 mg/kg
RSI = 1.2 mg/kg
109
What Ach-esterase inhibitor is primarily used in peds?
Edrophonium
110
What Ach-esterase inhibitor is primarily used at home by the patient?
Physostigmine
*remember from the Castillo lecture, you can use this to reverse but still keep the analgesic properties of a few drugs*
111
List these paralytics in increasing order of onset of action/duration: Neostigmine, Pyridostigmine and Edrophonium
Edrophonium (1 - 2 min and lasts 5 - 20) -> Neostigmine (7 - 11 min and lasts 40 - 60) -> Pyridostigmine (16 min and lasts 90)
112
What drug is commonly paired with neostigmine?
Glycopyrrolate (Robinul)
113
What anti-cholinergic commonly paired with paralytic reversal agents does not cross the BBB?
Glycopyrrolate
114
What are the important contraindications to Sugammadex?
Hx of MH, pseudocholinesterase deficiency and can increase plasma K concentration
115
What combination of drugs can offer an alternative to Sux?
RSI dose of Roc and reversal with Sugammadex
116
List the shallow/medium block, deep block and intense block reversal dosages of Sugammadex
Shallow = 2 mg/kg
Deep = 4 mg/kg
Intense = 16 mg/kg
117
What is the intubating dose of Pancuronium (pavalon)?
0.1 mg/kg
118
What is the intubating dose of Mivacurium (Mivacron)?
0.15 - 0.2 mg/kg
119
What is the intubating dose of Atracurium (Tracrium)?
0.5 - 0.6 mg/kg
120
What is the standard intubating dose of Sux?
1 mg/kg
121
What is the initial dose and max dose of flumazenil?
ID = 0.2 mg, max is 3 mg
122
What is the induction dose of ketamine?
0.5 - 1.5 mg/kg
123
What is the onset and duration of induction dose propofol?
Onset = 30 - 60 sec
Duration = 1 - 8 min
124
What is the onset of induction dose etomidate?
1 min
125
What is the onset and duration of induction dose ketamine?
Onset = 1 min
Duration = 10 - 20 min
126
What is the induction dose of versed?
0.1 - 0.2 mg/kg
*usually give a dose of fentanyl 50 - 100 mcg after administration of the benzo*
127
What is the onset and duration of induction dose versed?
Onset = 30 - 60 sec
Duration = 5 - 10 min
128
List the MAC, BG coefficient and vapor pressure of Sevo
MAC = 1.8
BG = 0.69
VP = 157
129
List the MAC, BG coefficient and vapor pressure of Des
MAC = 6.6
BG = 0.42
VP = 669
130
List the MAC, BG coefficient and vapor pressure of Iso
MAC = 1.17
BG = 1.46
VP = 238
131
List the MAC, BG coefficient and vapor pressure of NO
MAC = 104
BG = 0.46
VP = 38.770
132
What is the intubating dose, onset and duration of Sux?
1 - 1.5 mg/kg
Onset = 30 - 60 sec
Duration = 5 - 10 min
133
What is the intubating dose, onset and duration of Cisatracurium (Nimbex)?
Dose = 0.1 mg/kg
Onset = 2 - 3 min
Duration = 40 - 75 min
134
What is the intubating dose, onset and duration of Vecuronium (Norcuron)?
Dose = 0.1 mg/kg
Onset = 2 - 3 min
Duration = 45 - 90 min
135
What is the intubating dose, onset and duration of Roc (Zemuron)?
Dose = 0.6 mg/kg
Onset = 2 - 3 min
Duration = 35 - 75 min
136
What is the intubating dose, onset and duration of Pancuronium (Pavulon)?
Dose = 0.1 mg/kg
Onset = 2 - 3 min
Duration = 60 - 120 min
137
List the 5 paralytics on the clinical reference sheet in increasing order of duration of action
Sux -> Roc -> Nimbex -> Vec -> Pancuronium
*note, Roc, Nimbex and Vec are of very similar duration*
138
What is the 1:1 rule of Neo/Glyco administration?
For every 1 mg of Neo, you give 1 ml of Glyco
*be careful here, note the units, Glyco is generally 0.2 mg/ml, so for every 1 mg of neo you give 0.2 mg of glyco*
139
If you give 3.2 mg of Neo, how much Glyco are you giving?
0.64 mg or ~3 ml
*In practice, you would likely round that down to 3 mg of Neo and 0.6 mg of glyco/3 ml*
140
If you give 0.75 mg of Glyco, how much Neo are you co-administering with it?
3.75 mg
141
What is the dose range of Neostigmine?
0.04 - 0.07 mg/kg
142
What is the onset/duration of Neostigmine?
Onset = 5 - 10 min
Duration = 60 min
143
What is the onset/duration of sugammadex?
Onset = 1 - 4 min
Duration = 1.5 - 3 hours
144
What is the initial bolus and maintenance dose of LAST?
Bolus = 1.5 ml/kg of 20% lipids over 1 min
Maintenance = 0.25 ml/kg/min
145
What is the max repeat bolus dose of LAST?
3 ml/kg
*Be careful with the wording here, what is the max repeat BOLUS dose, not total dose*
146
What is the max total dose for LAST?
8 ml/kg IV
147
What can you increase the maintenance infusion rate for LAST resuscitation if BP continues to decline?
Increase from 0.25 to 0.5 ml/kg/min
148
What is the dose, onset and duration of Droperidol?
Dose = 0.625 mg
Onset = 1 - 5 min
Duration = 2 - 3 hr
149
What is the dose, onset and duration of Promethazine?
Dose = 6.25 - 25 mg
Onset = 1 - 5 min
Duration = 4 - 6 hr
150
What is the dose, onset and duration of Ondansetron?
Dose = 4 mg
Onset = 10 min
Duration = 4 - 9 hr
151
What is the dose, onset and duration of Dexamethasone?
Dose = 4 mg
Onset = 10 - 30 min
Duration = 2 - 10 hr
152
What is the dose, onset and duration of Scopolamine?
Dose = patch
Onset = 2 - 4 hr
Duration = 72 hr
153
What is the anti-emetic dose of Propofol?
10 - 15 mg IV followed by 10 mcg/kg/min (drip may not be needed)
154
What is the dosing range for Toradol?
15 - 30 mg q6h
155
What is the dosing range for Ibuprofen?
200 - 800 mg q6h
156
What is the standard concentration of ephedrine?
50 mg/ml
*To get to a usable concentration, dilute with 9 cc to get 5 mg/ml, then you can give the standard dose of 5 mg*
157
What is the standard concentration of Neosynephrine? Describe how to get it to a usable concentration
10 mg/ml
To get to a working concentration, you need to dilute it. Take 1 ml out and dilute with 9 ml of NS. Now you have 0.1 mg/ml or 100 mcg/ml
158
What is the dose and standard concentration of labetalol?
Dose = 5mg
Conc = 5 mg/ml
159
What is the dose and standard concentration of esmolol?
Dose = 10 mg
Conc = 10 mg/ml
160
What is the dose and standard concentration of hydralazine?
Dose = 5 mg
Conc = 20 mg/ml
161
What is the epidural and spinal dose range for Bupivacaine?
Epi = 0.0625 - 0.125%
Spinal = 1.25 - 2.5 mg
162
What is the epidural and spinal dose range for Ropivacaine?
Epi = 0.08 - 2%
Spinal = 2.5 - 4.5 mg
163
What is the lido w/epi epidural dose?
2% in 5 ml bolus
164
What is the epidural and spinal dose range for Fentanyl?
Epi = 50 - 100 mcg
Spinal = 10 - 25 mcg
165
What is the spinal dose range for morphine?
0.1 - 0.2 mg
166
What VAs can increase HR?
Des and Iso
167
How do VAs change Vt, RR and PaCO2?
All decrease Vt, increase RR and PaCO2 increases
168
What effects do VAs (other than NO2) have on: cerebral blood flow, ICP, CRMO and seizure likelihood?
CBF = increases
ICP = increases
CRMO = decreases
Seizure chance = decrease
*Note, N2O does all of the above except CRMO, N2O increases CRMO*
169
What volatile increases CRMO?
N2O
170
Which VAs most profoundly increase the length of a non-depolarizing muscle blockade?
Iso and Des
171
What effects do VAs have on: RBF, GFR and UOP?
RBF = decreases
GFR = decreases
UOP = decreases
172
T/F: VAs decrease hepatic blood flow
True
173
In general, would VA would be a good choice for a sick ICU patient that is unlikely to be extubated in the OR?
Iso
174
What 2 patient populations are at risk to develop issues with propofol?
Critically ill adults with head injuries on the infusion greater than 58 hours, and patients on high dose infusions (5 mg/kg/hr)
175
What induction agent would be a poor choice in a patient lacking GABA?
Etomidate
176
T/F: Rocuronium is not affected by renal failure
True
*It is prolonged by liver failure*
