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Shervin’s Cards For Repetition > Pharm Semester 2 - Test 2 > Flashcards

Pharm Semester 2 - Test 2 Flashcards

(103 cards)

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1
Q

What are the Ascending Sensory -Discriminative Tracts?

A

Spinothalamic and Trigemino-Thalamic Tracts

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2
Q

Medications target causes of pain by acting on these 4 mechanisms

A

Transduction- Starts at nerve endings /nociceptors
Transmission -Travel to nerve bodies
Modulation- Altering (inhibitory/excitatory) mechanisms at dorsal horn
Perception- Thalamus- central relay station and somatosensory cortex- discrimination

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3
Q

Afferent Fibers:
Which Type are Unmyelinated and which are myelinated and what kind of sensations do they sense

A

Unmyelinated: C- Fibers: burning from heat, pressure from sustained pressure. Slow, diffuse.
Myelinated: A Fibers:
Type 1- Aβ & Aδ: mechanical, chemical, heat
Type 2- Aδ : heat

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4
Q

Peripheral Pain Mediators:
Chemical Mediators:
Which ones are Peptides (4) and which is released first?

A

Bradykinin (1st released), Substance P, Calcitonin, CGRP

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5
Q

Peripheral Pain Mediators:
Chemical Mediators:
Lipids: (4)

A

Endocannabinoids, Leukotrienes, Prostaglandins, Thromboxanes

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6
Q

Primary Hyperalgesia: where and what causes it

A

At original site of injury. Caused by heat, mechanical injury, stress, & anxiety

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7
Q

Secondary Hyperalgesia:

A

Uninjured skin surrounding injury
From mechanical stimuli
- caused by Sensitization of neuronal circuits

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8
Q

Spinal Dorsal Horn acts as ____________ __________ for nociceptive and other sensory activity.

A

Spinal Dorsal Horn acts as Relay Center for nociceptive and other sensory activity.

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9
Q

The _________ ____________ travel to the brainstem and forebrain (S1 and S2): discriminating the ___________ and ___________

A

The Ascending Pathways travel to the brainstem and forebrain (S1 and S2): discriminating the location and intensity

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10
Q

Other name for Lamina 2?

Receptors here?

Fibers here?

A

Substantia Gelatinosa

Opioid Receptors

Afferent C-Fibers

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11
Q

Which Laminae have the Neurokinin 1 Receptor and what chemical mediator acts here?

A

Laminae 3 and 4

Substance P

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12
Q

A neurological gate at the spinal dorsal horn is aka a

A

Modulator

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13
Q

When gate is open, pain is projected to the _________ brain regions

A

Supraspinal

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14
Q

If Gate is Open (so you feel pain) from hitting elbow, which fibers send pain signals to brain?

A

Aδ -fibers: myelinated, small, fast.

C- fibers: Unmyelinated, slow.

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15
Q

When you rub a bumped elbow, which fibers “close the gate” by inhibiting some pain signals from reaching brain?

This is also how massage and ice stop pain

And what are the fibers’ characteristics?

A

Aβ-fibers - Myelinated, large diameter, fast.

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16
Q

What is the role of the Periaquaductal Gray (PAG) and the Rostral Ventral Medulla (RVM)

A

Descending Inhibitory Tract : Depress or facilitate integration of pain info. in the spinal dorsal horn

They descend down the spinal cord and stop the signals in spinal dorsal horn from ascending up to brain.

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17
Q

Spinal Cord Modulation:
Excitatory Impulses:

A

Glutamate (Glute Excites)
Calcitonin
Aspartate
Neuropeptide Y
Substance P

Glut CANS

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18
Q

Spinal Cord Modulation:
Inhibitory Impulses:

A

GABA
Glycine
Enkephalins
Norepinephrine
Dopamine

GG END

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19
Q

Supraspinal Modulation:
The Forebrain consists of ________ & _________ and interprets ___________ & ____________

A

S1 and S2 (Somatosensory areas)

Location & Intensity

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20
Q

When Pain Gate is Open, pain is projected to the

A

Supraspinal Regions= amygdala, brainstem, thalamus, somatosensory cortex

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21
Q

What are the Ascending Nociceptive Pathways (4)?

A

Spinothalamic- Pain

Spinomedullary

Spinobulbar - Behavior Toward Pain

Spinohypothalamic - Autonomic, endocrine, and emotional aspects of pain

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22
Q

What are the 2 Descending Pathways of Pain Modulation?
what do each do ?
Where do they originate and go down to ?

A

Descending Inhibition Pathway - Blocks Pain

Descending Facilitation Pathway - Amplifies Pain

They descend down the spinal cord and block the ascending signals in spinal dorsal horn from ascending up to brain.

Both originate in the PAG-RVM and go down to the spinal dorsal horn

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23
Q

Chronic Pain Definition and length of time

A

Persists beyond tissue healing

> 3 to 6 months

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24
Q

Neuropathic Pain:
A main characteristic ?
Leads to?

A

Persists after tissue has healed

Leads to Allodynia and hyperalgesia

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25
Allody*n*ia
Perception of pain in response to normally *n*on-painful stimuli
26
Visceral Pain: Definition, referred to, and causes
*Diffuse and poorly localized* Referred to: muscle and skin Causes: ischemia, stretching of ligaments, spasms, distention
27
Pain in Neonate starts at ? Pain perception in neonate and infant is characterized as having a ___________ pain threshold & _________ pain response
**23 weeks of gestation** Lower pain threshold and exaggerated pain response
28
What are the CV Responses to Pain (7)?
1) ↑ SVR → 2) HTN 3) Tachy (↑O2 demand) → 4) Myocardial Irritability → 5) *Compromised LV 6)↓ CO 7) Myocardial Ischemia*
29
What are the Pulmonary Responses to pain (6)?
1) ↑ total body O2 Consumption/CO2 Production 2) ↑ Vm & WOB 3) Decreased Chest Wall Movement 4) Atelectasis 5) Intrapulmonary Shunting 6) Impaired Coughing
30
Pain Response: GI/GU
1) Increased Sympathetic Tone 2) Decreased Motility => Ileus 3) Urinary Retention 4) Hypersecretion of Acid => Stress Ulcers & Aspiration 5) N/V **N/V Post Op could be Pain Related** 6) Abdominal Distention
31
Pain: Endocrine Response:
Increased: Glucagon, Renin, Aldosterone, Angiotensin Decreased: Insulin
32
Narcotic: Greek word for stupor which has potential to produce ___________ _______________
Physical Dependence
33
Opiod MOA: Presynaptic_____________ of the following neurotransmitters: _____________, _______________, ________________, _____________.
Presynaptic _Inhibition_ of _Substance_ _P_, _ACh_,_Norepinephrine_, and_Dopamine_,
34
Opioid MOA: Increased ________ conductance and ________ channel inactivation leads to **Decreased** _______________ of Pain ___________ or anti- nociceptive
Increased _Potassium_conductance (hyperpolarization) and _Calcium_ channel_ inactivation leads to **Decreased** **_Neurotransmission_** of _Pain_ _Modulators_ or anti- nociceptive
35
Where are the Opioid Receptors in the Brain?
Rostrum Ventral Medulla **(RVM)** Locus ceruleus Periaquaductal Gray **(PAG)** Hypothalamus
36
Where are Opioid Receptors found in Spinal Cord?
Interneurons and Primary Afferent Neurons in the dorsal horn **(Substantia Gelatinosa)**
37
Opioid Receptors Outside the CNS:
**Sensory** Neurons and immune cells
38
Which Opioid Receptors can cause Depression of Ventilation?
39
Which Opioid Receptor has Sedative Effects?
40
Which Opioid Receptors have the Highest Risk for Abuse Potential?
Mu2 and Delta
41
Which Opioid Receptors have the Lowest Risk for Abuse Potential?
42
Opiod S/E: CV:
**Orthostatic Hypotension**, Bradycardia, Decreased Venous return, CO, BP **Benefit**: Cardioprotective effects from Myocardial Ischemia
43
If given too much Opioids or Versed, can give which medication to antagonize the ventilatory depression but not the analgesia? Which pt’s is use of this medication contraindicated?
Physostigmine: anticholinesterase inhibitor; increases CNS levels of Acetylcholine (ACh) Avoid in patients where Increasing PNS activity would worsen issue: • Asthma • Bradycardia / Heart block • GI or GU obstruction • TCA overdose with cardiac conduction abnormalities
44
What does a Shift to the Right with the CO2 Response Curve with Opioids and Anesthesia mean?
Means there is a Decreased Sensitivity to CO2 & *body requires higher PaCO2 to trigger breathing*
45
Opioid: CNS S/E:
Decreased CBF, possibly ICP -**Caution w/head injury,** **Myclonus** with large doses, **Skeletal thoracic (chest wall) & abdominal muscle rigidity** -Tx: Naloxone (reverse opioid), BVM and muscle relaxants (Roc, SCh). If severe/unresponsive: intubation with neuromuscular blockade
46
Opioids: If accidentally give Opioids with ERCP and pt has spasms of Sphincter of Oddi (occurs 99% of time w/ fentanyl), what is treatment?
**Glucagon (2 mgs IV – give incremental). Benefit = no opioid antagonism**
47
Opioid: S/E: GU: Cutaneous: Placenta:
GU: urinary urgency Cutaneous: histamine release => flushed face, neck, & upper chest. Placenta: neonate depression; dependence (chronic)
48
Pharmacodynamic Tolerance is …
the development of requirement for increased drug doses (usually 2 to 3 weeks)
49
Opioids: _______________ is when opioid receptors on the cell membrane surfaces become gradually desensitized by reduced transcription & subsequent __________ in numbers of _________ ____________
_Downregulation_ is when opioid receptors on the cell membrane surfaces become gradually desensitized by reduced transcription & subsequent _decreases_ _in_ _numbers_ _of_ _opioid_ _receptors_
50
Which Opioid is the Gold Standard
Morphine
51
Morphine works more on ________ than ________ pain
Dull > Sharp
52
Morphine: Opioid Agonist: Dose: IV and IM Onset: IM Peak: IV Peak: Duration: Caution w:
Dose: 1-10 mg IV IM & IV Onset: 10-20 mins. IM Peak: 45 to 90 minutes **IV Peak: 15 to 30 mins** Duration: 4-5 hours **Caution w/Renal Pts- Longer Half Time**
53
Fentanyl’s Movement across Compartments:
IV (Plasma)=> VRG => Muscles => Fat => VPG
54
For Fentanyl the Lungs act as
Reservoirs
55
Fentanyl Metabolism with the Elderly? Hepatic Cirrhosis?
No Change Not Prolonged
56
Which has a Higher Context Sensitive Half Time? Fentanyl or Sufentanil?
Fentanyl
57
Sulfentanil binds 92.5% to which protein?
Alpha 1- Acid Glycoprotein
58
Remifentanil causes ___________ _________ of Ventilation with Propofol
Synergistic Depression
59
Remifentanil doses: Induction: Maintenance:
Induction: 0.5 to 1 mCG/kg IV (half fentanyl induction dose) over 30-60 seconds Maintenance: 0.25 to 1 mCG/kg IV or **0.005 to 2 mCG/kg/min IV**
60
Opioids Pharmacokinetic Properties: Morphine has the lowest?
% Protein Binding (35%) and Partition Coefficient (1) Lowest protein binding means more is active and eliminated faster. Table refers to lipid:water partition coefficient; Lowest => slower onset and delayed peak effect
61
Opioids Pharmacokinetic Properties: Alfentanil has the lowest?
PK (6.5), Vd (27) , and Clearance (238)
62
Opioids Pharmacokinetic Properties: Remifentanil has the lowest? And the highest?
Lowest: Elimination 1/2 T (.17-.33h), Context Sensitive Half- Time (4 min for 4 hr infusion), Effect Site Equilibration Time (1.1 min) Highest: Clearance (4,000 ml/min)
63
Opioids Pharmacokinetic Properties: Fentanyl has highest?
-Vd (335 L), -Elimination 1/2 T (3.1-6.6 h), -Effect- Site Equilibriation Time (6.8 min) -Context-Sensitive Half Time (260 min for 4 hr infusion)
64
What are the 8 Agonist-Antagonists Mentioned in Class?
Nalbu*phine* Nalor*phine* Buprenor*phine* De*zosine* Penta*zocine* Brema*zosine* Butorpha*nol* Meptazi*nol*
65
Least to Most Potent Opioid Agonists-Antagonists (8)
Meptazinol (100 mg =8mg Morphine) Pentazocine (1/5 as potent as Nalorphine) Dezocine (Less than Morphine) Nalbuphine (*= to morphine*) Nalorphine (*= to Morphine*) Bremazocine (2x > Morphine) Butorphanol (6-8x > Morphine) Buprenorphanol (50x > Morphine)
66
What are the Advantages of Opioid Agonist-Antagonists (4)?
**-Analgesia -Ceiling Effect prevents additional responses (additional doses wont increase response) -Limited Ventilation Depression -Low Potential for Physical Dependence**
67
Opioid Agonist-Antagonists: Bind to which receptors and what are effects?
• µ receptors: _partial effect_ (as agonist) or no effect (as competitive antagonist) • Κ and δ receptors: _partial effect_ (as agonist)
68
What does this graph illustrate?
The Ceiling Effect: Phenomenon where a drug’s impact on body plateaus; taking higher doses does not increase its effect. Partial agonists can produce a Plateau effect or a Ceiling effect
69
Opioid Agonist Antagonists: Pentazocine Agonist effects on which receptors? Excretion ?
Agonist effects on _δ and κ receptors_ with weak antagonist activity Excretion: Glucoronide conjugates = urine
70
Opioid Agonist-Antagonists: Pentazocine S/E?
S/E: sedation, diaphoresis, dizziness, dysphoria (high doses), **increased HR, BP, PAP, LVEDP**
71
Opioid Agonist-Antagonists: Butorphanol Receptors and level of affinity for each?
**σ: sigma** Minimal affinity → low dysphoria **µ:Mu** Low affinity → competitive ANTagonism at µ **κ:kappa** Moderate affinity → analgesia + anti-shivering
72
Naloxone is not effective as a reversal agent for which Opioid Agonist-Antagonist?
Bremazocine
73
Opioid Agonist-Antagonist: Nalbuphine CV S/E?
• CV: **no increase in BP, PA BP, HR, or atrial filling pressures => √√√ cardiac catheterization patients**
74
Opioid Agonist-Antagonist: Does Buprenorphine carry risk of withdrawal and have risk of abuse?
Yes carries risk of withdrawals. Low risk of abuse
75
Naloxone, Naltrexone and Nalmefene; which receptor and how do they act on receptor?
**Pure Mu Opioid Receptor Antagonists,** no agonist activity **Competitive Antagonists-** Bump opioid off and bind but don’t activate receptor
76
Opioid Antagonists: Naloxone Dose: IV: Dose: Continuous Infusion: Shock Dose: Epidural Dose:
• 1 to 4 mCG/kg IV • 5 µg/kg/HOUR IV continuous infusion • > 1 mCG/kg IV (shock) • Epidural S/E: 0.25 mCGg/kg/HOUR IV
77
Opioid Antagonists: Naloxone: Duration: S/E:
Duration **30-45 min.** S/E: reversal of analgesia, N/V, increased SNS (HR, BP, **pulmonary edema, cardiac dysrhythmias (v-fib)** *give slowly over 2-3 min. *
78
Naltrexone Duration: Nalmefene elimination 1/2 t:
Naltrexone Duration: 24 hours Used for alcoholism Nalmefene elimination 1/2 t: 10.8 hrs
79
Opioid Agonists: Relatively high dose (3mCG/ kg) of Fentanyl 30 min before sugical incision decreases ______________ ___________ ______________ of ______________ or _____________ to 50%.
** decreases Minimum Alveolar Concentration (MAC) of Iso or Desflurane to 50%** *Fentanyl has synergistic effect with the inhalation agents*
80
Suggested Starting PCA: Morphine: Basal Rate? Bolus Dose? Bolus interval (min)?
Basal Rate: 0-2 mg/h Bolus Dose: 1-2 mg Bolus interval (min): 6-10 min
81
Suggested Starting PCA: Hydromorphone: Basal Rate? Bolus Dose? Bolus interval (min)?
Basal Rate? 0 - 0.4 mg/h Bolus Dose? 0.2 - 0.4 mg Bolus interval (min)? 6-10 min
82
Suggested Starting PCA: Fentanyl Basal Rate? Bolus Dose? Bolus interval (min)?
Basal Rate? 0 - 60 mCG/h Bolus Dose? 20-50 mCG Bolus interval (min)? 5-10
83
What is the comparison of these 2 graphs demonstrating?
Better pain control; more even pain control with less peaks/valleys with PCA (on R) than with PRN doses (on L)
84
Neuraxial Opioids are effecting what area of the spinal cord? Targeting here does not block _____________ or ___________, or cause ___________
**Substantia Gelatinosa**= Lamina 2 Targeting here does not block sympathetics or senses, or cause weakness.
85
Neuraxial **Epidural** Opioid Dose is ____ - ______x __________ than **Spinal/Intrathecal/Subarachnoid Block (SAB)**
5-10x More than **Spinal/Intrathecal/Subarachnoid Block (SAB)**
86
Neuraxial Morphine has a __________ onset but ___________ duration
Slower onset but longer duration when given here.
87
Neuraxial Opioids: Epidural Uptake is in the _________ and __________ __________. Diffusion across the _______ => CSF. What is the Lipid Solubility here of fentanyl vs morphine
Epidural **fat** Epidural **venous** plexus = systemic absorption Diffusion **across the dura** => CSF. **Lipid solubility • Fentanyl (800x > morphine)**
88
Neuraxial Opioids: Spinal/Intrathecal/SAB Uptake: __________ ____________ in CSF depends on lipid solubility and can increase with ___________ __________. __________ accumulates more in spinal cord, remains in CSF and can migrate _________ .
**Cephalad movement** in CSF depends on lipid solubility and can increase with **coughing or straining** **Morphine accumulates more in spinal cord, remains in CSF and can migrate cephalad**
89
We do not want to block ______ - _______ which are our cardiac accelerators. Blocking these nerves=> __________, _________, ________.
T1-T4 Brady, Hypotension, asystole
90
Hyperbaricity: __________ Density medication is more dense than CSF so medication will _____________
High Sink
91
Hypobaricity: ___________ Density Medication than CSF so the medication will ___________ __________.
Lower Floats Upwards
92
Isobaric Solutions/Meds: Medication will _________ at the level of injection. Spreads more by ___________ than gravity.
Stay Diffusion
93
What local anesthetic baracity would affect the right hip of a patient positioned at the left lateral position?
Hypobaricity - medication needs to float to R hip
94
Neuraxial Opioids: 1) Epidural Admin: Longest CSF Peak: Medication and length of time? 2) Epidural Admin:Longest Plasma Peak: Medication and length of time? 3) Intrathercal/CSF/**Cervical Levels**: Medication and length of time?
1) Morphine: **1-4 hrs** 2) Morphine: **10-15 min** (similar to IM) 3) Morphine: **1-5 hrs**
95
Neuraxial Opioids: S/E: Pruritus: most common S/E, esp. in OB. Caused by? And Treatment?
Cephalad migration to **Trigeminal Nucleus** (brain stem) Tx: Naloxone, antihistamines, gabapentin
96
Neuraxial Opioids S/E: Depression of Ventilation Early within? Delayed within? Most Reliable Sign? Treatment?
• Early: within 2 hours • Delayed: 6 to 12 hours after • Most reliable sign: depressed LOC secondary to hypercarbia • Treatment: **Naloxone (0.25 mCG/kg/HOUR IV)** is effective in attenuating side effects (nausea and vomiting, pruritus)
97
After Neuraxial Opioids, mom should be instructed not to breast feed for _______
24 hrs
98
Which Opioid Antagonist has a use of treating Post Op ileus? What is its limitation?
Alvimopan • Uses: post op ileus • Limitations: long term use => CV events
99
What is the Dose of IVP Naloxone (Narcan)? What is the continuous infusion ? And how long is its duration?
**1-4 mCG/kg IVP** 5 mCG/kg/HR IV continuous infusion **Duration: 30-45 min** (Shorter than many Opioids’ duration)
100
What is the Dose of Naloxone (Narcan) for treating Epidural S/E?
0.25 mCGg/kg/HOUR IV infusion
101
What are the Side Effects of Naloxone (Narcan)?
• S/E: reversal of analgesia, N/V, Increased SNS (HR, BP, **Pulmonary Edema, Cardiac Dysrhythmias [V-Ffib])**
102
Which Opioid Antagonist is more effective PO, and is best for treating alcoholism ? How long is its duration?
Naltrexone 24 hours
103
What are the High Pulmonary First-Pass drugs used for anesthesia/sedation ?
Fentanyl, Sufentanil, Lidocaine, Bupivicaine, Prilocaine, Propofol *“Fentanyl Still Likes Bup, Pri, Prop”**

Shervin’s Cards For Repetition (5 decks)

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