Pharm Unit 3: Aspiration/PONV, Antiarrhythmics, Fluids, LA, Abx (FINAL) Flashcards
(306 cards)
1
Q
What types of drugs are used for aspiration prevention
A
H1 blockers
H2 blockers
PPI’s
Dopa receptor antagonists
2
Q
H1 blockers MOA
A
decreased contraction of intestinal smooth muscle
3
Q
H1 blockers uses
A
sedation
decreased GI motility
antimuscarinic
4
Q
what is the H1 blocker
A
diphenhydramine
5
Q
H2 blockers MOA
A
decrease acidity of gastric acid
6
Q
H2 blockers uses
A
ulcers
GERD
7
Q
H2 blockers common drugs
A
“tidine”
ranitidine
famotidine
nizatidine
cimetidine
8
Q
PPI MOA
A
inhibit acid secretion
9
Q
PPI uses
A
ulcers, GERD
10
Q
PPI common drugs
A
“prazole”
pantoprazole
omeprazole
lansoprazole
11
Q
dopamine receptor antagonist MOA
A
increase LES tone
increase GI motility
12
Q
dopamine receptor antagonist uses
A
GERD
diabetic gastroparesis
13
Q
dopamine receptor antagonist adverse effects
A
acute dystonic reaction
14
Q
common dopamine receptor antagonist
A
metoclopramide
15
Q
5HT3 antagonists MOA
A
block serotonin
- peripherally: vagal nerve terminals
- centrally: chemoreceptor trigger zone
16
Q
5HT3 antagonists uses
A
emesis due to vagal stimulation
17
Q
5HT3 antagonists adverse effects
A
QT prolongation
18
Q
5HT3 antagonists contraindications
A
pts w/prolonged QT interval
use w/ drugs that inhibit CYP enzymes
19
Q
common 5HT3 antagonists
A
“setron”
ondansetron
granisetron
dolasetron
palonosetron
20
Q
antimuscarinics uses
A
motion sickness
PONV
21
Q
antimuscarinics adverse effects
A
dry mouth
blurry vision
cognitive impairment
22
Q
common antimuscarinic for PONV
A
scopalamine patch
23
Q
D2 receptor antagonist MOA
A
block D2 receptor in CTZ
24
Q
D2 receptor antagonist adverse effects
A
acute dystonic reaction
prolonged QT
25
D2 receptor antagonist common drugs
"peridol"
droperidol
haloperidol
"azine"
perphenazine
promethazine
prochlorperazine
26
Neurokinin receptor antagonists MOA
inhibits substance P
27
Neurokinin receptor antagonist drug
Aprepitant
28
dexamethasone adverse effects
perineal burning, impaired glucose tolerance
29
Class IA antiarrhythmics
Quinidine
Procainamide
Disopyramide
30
Class IA antiarrhythmics MOA
block VG Na+ and VG K+ in myocytes
31
quinidine indications
PVC's
Systained VT/VF
Afib/Aflutter
short QT syndrome
32
quinidine adverse effects
N/V
diarrhea
tinnitus/hearing loss
hypotension
QRS & QT prolongation, torsades
33
quinidine contraindications
prolonged QT
34
Procainamide Indications
sustained VT, Afib in WPW
35
procainamide adverse effects
rash, myalgia, vasculitis, hypotension, bradycardia, QT prolongation, torsades, drug induced lupus
36
Procainamide Contraindications
prolonged QT
37
disopyramide indications
PVC's, VT
Afib
38
dispyramide adverse effects
urinary retention, constipation, glaucoma, QT prolongation, torsades
39
disopyramide contraindications
prolonged QT
40
Class IB Antiarrhythmics
Lidocaine
Mexiletine
41
Class IB Antiarrhythmics MOA
block VG Na+ in myocytes
42
Class IB Antiarrhythmics indications
V tach, V fib
43
Class IB Antiarrhythmics adverse effects
increased potency in ischemic tissue, GI effects
44
lidocaine SE
visaul disturbances
tremor
seizure
drowsiness
hallucination/coma
asystole
hypotension
N/V
45
Mexiletine SE
GI upset
N/V
blurred vision
tremor
headache
ataxia
confusion
46
Class IB Antiarrhythmics contraindications
atrial tachyarrhythmias, HF/liver disease
47
Class IC antiarrhythmics
Flecainide, Propafenone
48
Class IC antiarrhythmics MOA
dramatically prolong phase 0 in myocyte AP (block VG NA+)
49
Class IC antiarrhythmics indications
AFib (w/o CAD), SVT
50
flecainamide adverse effects
dizziness, dyspnea, headache, blurred vision, nausea, HF exacerbation, AV block, VT/VF in pt's with CAD
51
flecainamide contraindications
heart failure
CAD
52
propafenone adverse effects
dizziness, dyspnea, headache, blurred vision, nausea, bradyccardia
bronchospasm
53
propafenone contraindications
heart failure
CAD
asthma
54
Class II antiarrhythmic drugs
beta blockers
55
beta blockers MOA
decreased slope of phase 4 depolarization
prolong depolarization at AV node
56
beta blocker indications
Afib/Aflutter (slow HR down)
SVT's
ventricular arrhythmia prevention
***will not convert back into normal sinus***
57
beta blocker adverse effects
fatigue
hypotension
bronchospasm
mask hypoglycemic symptoms
aggravation of heart failure
58
Class III antiarrhythmics
Amiodarone
59
Class III MOA
K+ blocker
-- prolongs QT interval
60
Class III SE
torsades the pointes
higher proarryhthmia risk
61
Amiodarone MOA
K+ blocker (high)
- prolongs AP duration
- phase 3
Na+ blocker
Ca2+ blocker
beta blocker (slow SA/AV conduction)
62
when does amiodarone work best?
at high heart rates due to use-dependence
63
amiodarone indications
VT/VF
SVT
Afib/Aflutter
64
amiodarone features
lg volume of distribution due to lipophilicity
requires loading dose (10g)
delayed onset
long half life (2 months)
65
amiodarone adverse effects
pulmonary toxicity
liver injury
hypotension
bradycardia
AV block
worsening dysrhthmias
thyroid abnormalities
66
amiodarone contraindications
hypersensitivity (iodine)
cardiogenic shock
bradycardia
AV blocks
67
amiodarone drug interactions
digoxin
warfarin
statins
68
amiodarone metabolism
hepatic by CYP3A4 and 2C8
69
amiodarone inhibits
CYP3A4
CYP2C9
P-glycoprotein
70
Class III drugs that can cause torsades
dofetilide
sotalol
71
dronedarone compared to amiodarone
less efficacy than amiodarone
does not contain iodine
72
dronedarone SE
GI impacts
73
dronedarone indications
atrial flutter
afib
74
Class IV antiarrhythmics
non-DHPR CCB's
verapamil
diltiazem
75
non-DHPR CCB MOA
inhibition of L-type Ca2+ channels (phase 0 in nodal tissue)
slow depolarization in pacemaker cells
76
non-DHPR CCB indications
SVT
Afib/Aflutter
77
non-DHPR CCB adverse effects
hypotension
bradycardia
AV block
decreased SV
78
adenosine adverse effects
dyspnea
bronchospasm
flushing
chest pressure
79
Adenosine indications
SVT
80
digoxin MOA
increases parasympathetic tone via vagus nerve
-- decr sinus node
-- prolongs AV node refractory
inhibits Na/K-ATPase pump
--incr Ca2+
--incr contractility
--incr proarrhythmic potential
81
digoxin indications
atrial fibrillation
aflutter
heart failure w/ reduced EF
82
digoxin CI
afib
aflutter
WPW
83
digoxin adverse effects
narrow therapeutic window
GI upset
halo vision
malaise
bradycardia
AV block
VT/VF
84
when is digoxin used?
on a resting heart rate
-- pt is just sitting not walking around
rate control in combination with BB/CCB
85
Antimuscarinics indications
bradycardia
AV block
86
antimuscarinic side effects
dry mouth
blurry vision
photophobia
tachycardia
87
antimuscarinic drugs
atropine
glyco
88
antimuscarinic MOA
block ACH from binding to muscarinic receptors
alters parasympathetic response
anti-parasympathetic drugs
89
preop causes of volume derangements
bowel preps
bowel obstruction
pancreatitis
blood loss
90
anesthetic causes of volume derangements
anesthetic hypotension
(vasodilation)
sympathetic blockade
91
surgical causes of volume derangements
hemorrhage
coagulopathy
decreased venous return
long operative time
92
when is hypervolemia clincally significant
>10% above basewline
93
hypervolemia SE
incr morbidity
tissue edema
impaired wound healing
pulm edema
decr GI motility
94
what lab value reflects total body water status
serum sodium
95
what content in IV fluid dictates fluid distribution?
Na+
96
what factors influence total body water content
gender
age
nutritional status
disease state
97
TBW and age relationship
less water with increased age
98
neonates TBW
70-80% of body weight is water
99
calculating TBW
50-60% of body weight
100
ICF:ECF
2:1
2/3 ICF and 1/3 ECF
101
ECF
interstitial fluid (3)
plasma (1)
ISF: plasma = 3:1
102
electrolyte content of ECF
Na+
Cl-
103
electrolyte content of ICF
K+
Phosphate
104
what is colloid osmotic pressure
pulls fluid into vessels
105
what maintains fluid components of blood within vessels?
colloid osmotic pressure (oncotic pressure)
106
what changes oncotic pressure
allbumins
proteins
etc
107
what is hydrostatic pressure
pushes fluid out of vessels
108
what is osmolar force
push and pull in and out of vessels
109
what does lactate do in LR?
provides circulating bicarb to provide normal HCO3- levels during acidosis
???????
110
what is the main contributor of osmolarity
sodium
111
Tonicity of Crystalloids
isotonic
112
Distribution of water
ECF and ICF
113
distribution of saline/LR
distributes only to ECF
114
distribution of colloids
distributes only to intravascular space
115
colloid types
albumin
hetastarch
dextrans
116
HES SE
acute kidney
incr moprtaloity
incr need to PRBC transfusion
117
albumin
source of capillary oncotic pressure (80%)
118
types of albumin
hyperoncotic (25%)
5% albumin (isotonic to plasma)
119
pts low in albumin
nutritionally deficient
renal disease
liver disease
120
most potent colloid
25% albumin
121
Hetastarches (HES)
amylopectin and synthetic glycogen
122
HES molecular weight
high MW = slower degradation
123
Dextrans
long chains of glucose (polysaccharides)
124
Dextran unique property
rhological properties
-- moderate plt function
-- antithrombotic
used in vascular sx to prevent post-op stroke
125
typical water loss per day
2.5 L/day
126
causes of increased water loss
fever
sweating
gastric
colon
insensible losses
127
normal Na loss
77 mEq/day
128
normal K loss
40-60 mEq/day
129
normal Cl loss
same as sodium
130
where will LR/Saline distribute
ECF- 1/4 IV 3/4 IS
131
where will D5W distribute
ECF and ICF proportionally
132
where will Albumin distribute
intravascular space
133
best fluid for maintenance
D5W + 0.225% NaCl
134
best fluid for metabolic acidosis
LR
135
preferred IVF in anesthesia
LR
136
which colloid solutions have a risk for bleeding
6% hetastarch, Dextran 40
137
how to calculate total body water
0.6L/kg
138
N/S SE
hyperchloremic acidosis
reduction of renal perfusion
139
water distribution
across all compartments
vascular compartment
Interstitial space
cell membranes
140
Na+ distribition
capillary membrane
interstitial fluid
pumped out of cell
141
colloids distribution
confined to vascular compartment
does not cross into capillary membrane
142
crystalloids use
mx
replacement of losses
treatments of symptoms
-- fluid or electrolyte deficits
143
colloids uses
add oncotic pressure
volume replacement
rheologic propoerties
144
sensible loses
measurable
145
insensible losses
respriation
fever
evaproration (surgical)
146
adult fluid maintenance
30mL/kg/day
147
minimal losses
0-2 mL/kg
148
moderate losses
2-4 mL/kg
149
severe losses
4-8 mL/kg
150
what fluid dosing is recommended during major invasive surgery?
zero balance approach
- only fluid lost is replaced
151
mechanism of action of local anesthetics
Block voltage-gated sodium channels
152
what does Blockage of voltage-gated sodium channels do
blocks generation and conduction of action potentials
153
when do local anesthetics gain access to Na channels
during activated state
154
when is the affinity of LA for Na channels greater
when Na channels are open
155
what does the lipophillic region of LA affect
onset of action
potency
duration
156
increasing lipophilicity
increases potency
slower onset
157
what does ester or amide linkage of LAs affect
duration of action
158
if someone has an allergy to amid local anesthetics, can you safely give an ester?
yes (& vice versa)
159
what does a higher % neutral affect
enhanced absorption
160
how does % neutral affect absoprtion
neutral form penetrates the membrane
161
what do we want the pKa of the LA to be
closest to physiologic pH
162
what is the determining factor for LA toxicity
vascularity
163
Vascularity ranking Highest to lowest
HIGH
IV
tracheal
intercostal
caudal
paracervical
epidural
brachial plexus
subarachnoid/sciatic/femoral
subQ
LOW
164
what does the risk for systemic LA toxicity depend on
lipid solubility
amount of connective tissue in area
pH of tissue
% neutral
is epi added?
165
how does lipophilicity and tissue protein binding affect duration
remains in tissue longer
166
how does epi affect the LA
makes LA more acidic
167
what does bicarb addition to epi + LA
makes it neutral for a faster onset
168
what delays LA redistribution
vasoconstriction
169
why is epi added to local?
prolongs duration of action
reduced peak serum concentration
170
onset of LA: lipid solubility
less lipid soluble = less potent
(typically delays onset)
171
duration of action of LA
potency
lipid solubility - more = slower diffusion = longer DOA
172
what type of axon is more sensitive to LA blcok
myelinated
173
what is the most common feature of LAST
seizures
174
what does a low CC/CNS ratio mean
more cardiotoxic
175
what does a high CC/CNS ratio mean
more CNS toxiv
176
what type of pt is at increased risk for LAST
pregnant elderly
neonate
177
how to treat LAST
lipid emulsion 20% IV, 100 ml bolus over 2-3 min
rebolus 200 mil over 15-20 in
178
Lidocaine maximum dose
4.5 mg/kg
179
Lidocaine + Epi maximum dose
7 mg/kg
180
ropivacaine max dose
2.5 mg/kg
181
bupivacaine max dose
2.5 mg/kg
182
lidocaine pKa
7.6
183
ropivacaine/bupivacaine pKa
8.1
184
how does pKa affect onset
pKa closer to physiologic pH = higher % neutral, faster onset
185
which local anesthetics can cause methemoglobinemia
prilocaine and benzocaine
186
which local anesthetics are more cardiotoxic
bupivacaine
187
which local anesthetics are more CNS toxic
mepivacaine
188
what does extreme lipophilicity promote
continued binding and increased duration of action
189
LA that is extremely lipophilic
bupivacaine
190
what LA property does protein binding affect
duration of action
191
what LA property does pKa affect
onset of action
192
what correlates with toxicity risk
Cmax
time to Cmax
193
what drugs could be used to manage LA systemic toxicity
epinephrine, amiodarone
midazolam
lipid emulsion
194
What is the minimum inhibitory concentration (MIC)?
lowest concentration of a given antimicrobial that will inhibit an organisms growth
195
bacteriostatic
do not kill organism
interfere w/growth/replication
196
bacteriocidal
kill the organism
197
how is antibiotic susceptibility related to MIC
MIC increases with reduced susceptibility
198
when does resistance occur
when MIC exceeds the tolerable dose
199
What is the post-antibiotic effect?
Bacterial killing continues after the serum level drops below the MIC
200
what is time dependent killing
cidal activity continues as long as the concentration in plasma is greater than MIC
201
for a long surgery, what abx do you need to re-dose
time-dependent agents
202
what is an example of time dependent killing
beta lactams
203
what is concentration dependent killing
efficacy increases as concentration increases
204
examples of concentration dependent killling
aminoglycosides and quinolones
205
what type are antibiotics are typically bacteriostatic
protein synthesis inhibitors
206
characteristic of a bacteriostatic antibiotic
interfere with growth and replication
207
what is empiric therapy
treat based on most likely organisms
208
what type of antibiotics are typically bactericidal
cell wall acting
209
when are bactericidal abx always used
immunosuppressed or severe infection
210
definitive therapy
treat based on identified organism
211
preventative therapy
prophylaxis based on the most likely organism
212
post antibiotic effect
Persistent suppression of bacterial growth after antibiotic concentration has fallen below the specified MIC is known as
213
Antibiotic which may prolong the neuromuscular blocking effects of rocuronium
levofloxacin
214
When this agent is combined with ampicillin, it extends the spectrum of activity to be active against more gram negative and anaerobic bacteria
sulbactam
215
The mechanism of action of cefotetan is
inhibition of crosslinking of peptidoglycan to inhibit bacterial cell wall synthesis
216
Prolonged QT on ECG and cardiac arrhythmia is a possible risk with
quinolones
217
antibiotic to avoid in a pregnant patient
doxycycline
218
Agent that may be used for decolonization of patients who are nasal carriers of MRSA and MSSA
mupirocin
219
vancomycin is associated with all of the following adverse effects except
bleeding
220
Select the antiemetic agent that is associated with dry mouth, blurry vision, and may cause cognitive impairment in elderly patients:
scopalamine
221
An agent that may be useful for late or delayed nausea and vomiting:
palonosetron
222
Dexamethasone IV injection has been associated with:
perineal burning sensation
223
A patient treated with droperidol in the PACU develops an acute and painful cervical dystonic reaction. Select appropriate therapy to relive the dystonia
diphenhydramine or glycopyrrolate
224
Are beta lactams bactericidal or bacteriostatic?
bactericidal
225
beta lactams MOA
Inhibition of cell wall synthesis: Interference with peptidoglycan crosslinking
226
penicillins spectrum
G+, G-,
non-b lactamase anaerobes (broad spectrum) (streph/staph)
227
Penicillins: Adverse Effects
hypersensitivity reaction, seizure
228
difference between cephalosporins and penicillins
more stable against bacterial beta lactamase
229
1st gen cephalosporin
Cefazolin
230
1st gen cephalosporin coverage
gram positive, some gram negative
231
2nd gen cephalosporin
Cefotetan (also anaerobes)
cefoxitin
232
2nd gen cephalosporin coverage
gram positive, more gram negative
233
3rd gen cephalosporin
Ceftriaxone
234
3rd gen cephalosporin coverage
decreasing gram positive, increasing gram negative
235
4th gen cephalosporin
Cefepime
236
4th gen cephalosporin coverage
G+, G-, pseudomonas
237
5th gen cephalosporin
Ceftaroline
238
5th gen cephalosporin coverage
MRSA
239
cephalosporin adverse effects
allergy, bleeding, disulfiram reaction
240
beta lactamase inhibitors
Clavulanate (amoxicillin or ticarcillin/clav
Sulbactam (ampicillin/sulb)
Tazobactam (piperacillin/tazo)
241
beta lactamase inhibitors MOA
inactivate beta lactamase to make other abx more active
242
carbapenems
Meropenem, Ertapenem
Doripenem
243
carbapenems MOA
inhibit cell wall synthesis (resistant to beta lactamases)
244
Carbapanems spectrum
gram positive, gram negative
anaerobes
pseudomonas
245
Carbapenems adverse effects
seizure, renal impairment
246
beta lactamase inhibitors spectrum
G+, G-
anaerobes
247
vancomycin MOA
inhibits synthesis of cell wall precursors
D-Ala terminus inhibiting crosslinking
248
Vancomycin spectrum
Gram +: enterococcus
MRSA
C. Diff
249
what do we try to reserve vancomycin for?
MRSA treatment
250
Vancomycin adverse effects
nephrotoxicity
ototoxicity
red man syndrome
251
vancomycin infusion time
1 hr
avoids red man syndrome
252
is vancomycin a beta lactam
No
253
what drug is an alternative for penacillin allergies
vancomycin, macrolides
254
aminoglycosides
gentamicin
neomycin
amikacin
255
what drug is related to bowel prep or irrigation?
neomycin
256
aminoglycosides MOA
inhibit bacterial protein synthesis (30S subunit)
257
Are aminoglycosides bactericidal or bacteriostatic?
bactericidal
258
Aminoglycosides adverse effects
ototoxicity
nephrotoxicity
prolong neuromuscular blockade (NDMR)
259
macrolides
erythromycin
clarithromycin
azithromycin
260
macrolides MOA
inhibit protein synthesis (50S subunit)
261
macrolides spectrum
G+, pneumococci
262
macrolides adverse effects
GI effects, inhibit CYP 450
263
tetracyclines
Tetracycline, Doxycycline
Minocycline
264
tetracyclines MOA
inhibit protein synthesis (30S subunit)
inhibit adding next amino acid
265
Are tetracyclines bacteriostatic or bactericidal?
bacteriostatic
266
tetracyclines spectrum
Gram (+), mycoplasma, H. pylori, Chlamydia
267
tetracyclines adverse effects
GI altered flora
268
tetracyclines contraindications
pregnancy
causes bone deformities and teeth issue in fetus
269
clindamycin MOA
inhibit protein synthesis (50S subunit)
270
Is clindamycin bacteriostatic or bactericidal?
bactericidal
271
clinda spectrum
most gram pos
most anaerobes
272
Clindamycin adverse effects
C. diff, GI effects
273
oxazolidinones
Linezolid
274
oxazolidinones MOA
prevents formation of ribosome complex
23s ribosomal rna on 50s subunit
275
oxazolidinones spectrum
G+ (MRSA, VRE, VRSA)
vanc resistant enterococci
276
what do we reserve linexolid for
MRSA
vanc-resistant MRSA
277
oxazolidinones adverse effects
MAO activity (degrades catecholamines - HTN response)
hematological (anemia, thrombocytopenia)
neuropathy
278
DNA synthesis inhibitors
Quinolones
279
quinolones
Ciprofloxacin
Levofloxacin
Ofloxacin
lomefloxacin
perfloxacine
280
quinolones MOA
inhibit topoisomerase II (DNA gyrase)
inhibit topoisomerase IV
281
quinolones spectrum
Broad (G+ and G-)
do not cover anaerobes
282
Quinolones adverse effects
glycemia
QT prolongation
growing cartilage (CI for preg/peds)
tendonitics
enhance NMB
283
quinolones CI for what pts
pregnant
peds
284
antimetabolites (antifolates)
sulfonamides
285
sulfonamides MOA
inhibit folate synthesis
(inhibit purine/DNA synthesis)
286
sulfonamides spectrum
gram positives
287
sulfonamides adverse effects
megaloblastic anemia,
leukopenia
granulocytopenia
vasculitis
cross reactivity
288
metronidazole use
add when worried about anaerobes
289
when to use metronidazole
abdominal
absesses
mixed infection
290
mupirocin use
MRSA nasal colonization
291
polymixins use
bactericidal for abdominal procedures
292
when should the antibiotic be administered?
60 min prior to incision
293
when should vanc and quinolone be administered
120 min prior to incision
294
when should you give cefazolin?
30 mins prior
295
when do you redose abx
sx longer than 4 hrs
major blood loss
296
how long do you mx prophylaxis of abx
duration of sx
not greater than 24 hrs
297
what is commonly used when there is a PCN allergy
vancomycin, clindamycin, erythromycin
298
what abx do you give for b lactam allergy
vancomycin
clindamycin
299
abx that impact NMJ (slower reversal)
aminoglycosides
quinolones
polymyxins
tetracyclines
clindamycin
300
reversal of abx NMB prolongation
calcium
neostigmine (not polymixin)
301
pt allergic to penicillin: what do you avoid?
penicillin
cefaclor
cefadroxil
cefatrizine
cefprozil
cephalexin
cephradine
302
can you use cefazolin w/penicillin allergy
yes
303
what drugs should you avoid in pregnancy in third trimester
TMP/SMX
- displace bilirubin from albumin
304
what drug should you avoid in all trimesters?
doxycycline
tetracycline
quinolones
305
SCIP
quality measures to medicare for public display
306
