PharmExamIV Flashcards
(271 cards)
1
Q
What is the other name for neuromuscular monitoring?
A
Acceleromyography
2
Q
The most common location, nerve, and muscle monitored are?
A
hand, ulnar nerve, adductor policis
3
Q
What are the long acting NDNMBs?
A
Pancuronium
4
Q
What are the intermediate acting NDNMBs?
A
- Rocuronium
- Vecuronium
- Cisatracurium
- Atracurium
5
Q
What are the short acting NDNMBs?
A
Mivacurium
6
Q
What two reversal agents are normally paired together?
A
Neostigmine and Glycopyrolate
7
Q
What is the mechanism of action for AChE inhibitors?
A
Inhibit acetylcholine esterase at the NMJ, so that ACh can bind and cause muscle contraction.
Competitive antagonists
8
Q
What subunits do ACh bind to?
A
Alpha
9
Q
What locations do NMBD reversal agents work at?
A
Preganglionic (SNS & PNS)
NMJ (primary)
10
Q
What is the ceiling effect?
A
The point at which the drug will no longer have any effect
11
Q
What is the max dose of neostigmine?
A
5 mg
12
Q
What is the max dose of Edrophonium
A
1 mg/kg
13
Q
How many twitches do we need to see before we can reverse?
A
1-2 twitches. Muscular blockage cannot be reversed if there are 0 twitches.
14
Q
What are the 5 factors that influence the reversal of NMB?
A
- Depth of block
- AChE inhibitor choice
- Dose administered
- Rate of plasma clearance
- Anesthesia agent choice and depth
–> Postoperative residual NM blockade
15
Q
What is the dose range of neostigmine?
A
0.04-0.07 mg/kg
OR
40-70 mcg/kg
16
Q
What’s important to note regarding paralytics and their reversal agents?
A
The paralytics can last longer than the reversal agents.
17
Q
What is the onset time of neostigmine?
A
5-10 minutes
18
Q
What is the duration of action for neostigmine?
A
60 minutes
19
Q
How is glycopyrolate dosed with neostigmine?
A
0.2 mg per mg of neostigmine
20
Q
What is the dose for sugammadex?
A
2-16 mg/kg
21
Q
What is the onset time of sugammadex?
A
1-4 minutes
22
Q
What is the duration of sugammadex?
A
1.5-3 hours
23
Q
What is the dose for succinylcholine (Anectine)?
A
1-1.5 mg/kg
24
Q
What is the onset of succiynlcholine (Anectine)?
A
30-60 seconds
25
What is the duration of action for succinylcholine (Anectine)?
5-10 minutes
26
What is the dose for pancuronium (Pavulon)?
0.1 mg/kg
27
What is the onset for pancuronium (Pavulon)?
2-3 minutes
28
What is the duration of pancuronium (Pavulon)?
60-120 minutes
or
1-2 hours
29
What is the dose for cisatracurium (Nimbex)?
0.1 mg/kg
30
What is the onset for cisatracurium (Nimbex)?
2-3 minutes
31
What is the duration for cisatracurium (Nimbex)?
40-75 minutes
32
What is the dose for vecuronium (Norcuron)?
0.1 mg/kg
33
What is the duration for vecuronium (Norcuron)?
45-90 minutes
34
What is the onset for vecuronium (Norcuron)?
2-3 minutes
35
What is the dose of edrophonium?
0.5 to 1 mg/kg
36
What is the onset of edrophonium?
1 to 2 minutes
37
What is recurarization?
An increase in neuromuscular block after a variable period of recovery.
| Patient becomes paralyzed again
38
# If our dosage was 50mcg/kg
How much neostigmine will you administer in mL for a 100kg patient?
| Neostigmine is available at 1 mg/mL
39
What is the renal excretion of the NMBD reversal agents?
| Neo, Pyrido, and Edroph
Neo is 50%
Pyrido and Edrop are 75%
40
What does CRF do to plasma clearance? How does this affect our reversal agents?
Renal failure **decreases** plasma clearance and **increases** the duration of action.
41
What are the primary side effects of NMBD reversal drugs?
**Increased nicotinic/muscarinic activty**
CV: brady, asystole, arrythmia
Pulm: **bronchoconstriction**, salivation
GI: **PONV**, gastric fluid secretion
Eyes: Miosis
42
What reversal agent is preferred for cardiac disease?
Glycopyrrolate
43
What anti-cholinergic/anti-muscarinic is given to prevent side effects with Edrophonium?
Atropine: 7-10 mcg/kg
44
What anti-cholinergic/anti-muscarine is given to prevent side effects with neostigmine and pyridostigmine??
Glycopyrrolate
45
# 10 mcg/kg is the dose for this patient
How much neostigmine will you administer in mL for a 100kg patient?
| Neostigmine is available at 0.2 mg/mL
46
What is the mechanism for persistent NM blockade?
Acetylcholinesterase is maximally inhibited and no further anticholinesterase is effective
47
What is the MoA of sugammadex (Bridion)?
Encapsulates and binds the NMBD molecules
Binds to free drug in the plasma (not proteins)
**Forms a concentration gradient using hydrophobic interactions**
48
What is the elimination 1/2 time of Sugammadex (Bridion)?
2 hours
49
What is the major route of elimination for sugammadex (Bridion)?
Urine
70% in 6 hours
90 % in 24 hours
50
How are neostigimine and edrophonium cleared if renal function is impaired?
30-50% hepatic clearance
51
What type of molecule is sugammadex (Bridion)? What are its properties?
γ-cyclodextrin
dextrose units from starch
Highly water soluble
52
What are dose related sugammadex (Bridion) side effects?
N/V
Pruritis
Urticaria
53
How do you readminister roc or vec after reversal (up to 4mg/kg bridion)?
Wait 5 minutes and then administer 1.2 mg/kg rocuronium
| If NMB is req before recommended waiting time, use nonsteroidal NMBD
54
What are some contraindications for sugammadex?
1. Oral contraceptives
2. Toremifene (no-steroidal anti-estrogen) - displaces NMBD from sugammadex
3. Heparin - Coagulopathy/Bleeding
4. Less than recommended doses - Recurarization
55
What are the s/s of recurarization?
1. Can verbalize - suffocating feeling
2. Unable to sustain head lift or hand grasp
3. **Pharyngeal collapse and respiratory obstruction**
56
How do we treat recurarization?
1. Re-sedate patient
2. Give additional reversal agents in divided doses (Neo 0.05 mg/kg IV = longer DoA)
57
What is the clinical duration of response for pancuronium?
86 minutes
58
What is the clinical duration of response for rocuronium?
36 minutes
| Rocky is 36 minutes late
59
What is the clinical duration of response for vecuronium (Norcuron)?
44 minutes
60
What is the clinical duration of response for atracurium?
46 minutes
61
What is the clinical duration of response for cisatracurium (Nimbex)?
45 minutes
62
What is the clinical duration of response for mivacurium?
16.8 minutes
63
What preservative is found in both esters and amides that can cause allergies?
Methylparaben
64
What are the S/S of IgE anaphylaxis?
Rash
Urticaria
**Laryngeal edema**
hypotension
bronchospasm
65
What is LAST?
Local Anesthetic Systemic Toxicity
Results from an **excess plasma concentration** of the drug
| Entrance into the systemic circulation
66
What does LAST depend on?
Dose
Vascularity of site
Epinephrine
Physiochemical properties
67
What is the order of the blood concentration at LA injection sites from the highest to the lowest?
1. IV
2. Tracheal
3. Caudal
4. Paracervical
5. Epidural
6. Brachial
7. Sciatic
8. Subcutaneous
| ITCPEBSS
68
What is the dose dependent effect of Lidocane at 1-5 mcg/mL?
Analgesia
69
What is the dose dependent effect of Lidocane at 10-15 mcg/mL?
Seizures
Unconciousness
70
What is the dose dependent effect of Lidocane at 15-25 mcg/mL?
Apnea
Coma
71
What is the dose dependent effect of Lidocane at >25 mcg/mL?
cardiovascular depression
72
What is the dose dependent effect of Lidocane at 5-10 mcg/mL?
| most effects...
Circumoral numbness
Tinnitus
Skeletal muscle twitching
Hypotension
Myocardial depression
73
How does lidocaine cause cardiovascular affects?
**Block cardiac Na+ channels**
Slows conduction of cardiac impulses
Prolongs PR interval & causes QRS widening
74
Which local anesthetic causes the worst cardiovascular system effects?
Bupivacaine
Latches onto cardiac muscle?
| **Bupivacaine > Ropivacaine > Lidocaine**
75
What two factors predispose our OB population to local anesthetic toxicity?
1. Decreased plasma esterases
2. Decreased plasma proteins
76
What are the 3 goals of LAST treatment?
1. Prompt airway management
2. Circulatory support
3. Removal of LA from receptor sites
77
What drugs are used to treat LAST?
| There are several
100% oxygen
Barbituates
Benzodiazepines
Epinephrine
**Propofol
Muscle Relaxants
Intralipid**
| Medications given depends on the symptoms seen
78
What is intralipid? What is the MoA?
Intralipid is lipid emulsion therapy that creates a lipid compartment. The lipid emulsion acts as a "sink" for the lipophilic (fat-soluble) local anesthetic molecules. The local anesthetic molecules diffuse from the tissues and plasma into the lipid phase of the emulsion, reducing their concentration in the bloodstream and tissues.
79
If the patient does not respond to intralipid, what is the next step?
CPB/ECMO
80
What is the dose for intralipid?
1.5 mL/kg of 20% lipid emulsion
0.25 mL/kg/minute infusion for at least 10 minutes
| **Max dose: 3.8 mL/kg (1.2 to 6 mL/kg) in 30 minutes**
81
16,200 mgs
82
What are the 3 categories of neural tissue toxicity from LAs?
1. Transient Neurological Symptoms (TNS)
2. Cauda Equina Syndrome
3. Anterior Spinal Artery Syndrome
| Either transient or permanent neurological injury
83
What are transient neurological symptoms?
**Moderate to severe pain** (lower back, buttocks, & posterior thighs) within 6 to 36 hours after uneventful single-shot SAB
84
What is the treatment for transient neurological symptoms?
1. Trigger point injections
2. NSAIDS
85
What is cauda equina syndrome?
**Diffuse injury at the lumbosacral plexus**
Varying degrees of: sensory anesthesia, **bowel and bladder dysfunction**, & **paraplegia**
| Associated w: disc hernation, prolapse, or sequest w urinary retention
86
What is anterior spinal artery syndrome?
**Lower extremity paresis with a variable sensory deficit**
The cause is uncertain. It could be a thrombosis or a spasm of the bilateral anterior spinal artery.
87
Which LAs can cause methemoglobinemia?
Prilocaine > benzocaine > lidocaine
Nitroglycerine, phenytoin, and sulfonamides also cause metHgb
| Pril, Benny, and Liddy met
88
What is the dosage for methylene blue?
1 mg/kg over 5 mintutes (max 7 to 8 mg/kg)
| Reversal from ferric Hgb to ferous Hgb is within **20-60 minutes**
89
What are CO2 retainers susceptible to?
Lidocaine depressing the ventilatory response to arterial hypoxemia
90
What is the primary cause of hepatotoxicity with LAs?
Continuous or intermittent epidural **bupivacaine** to treat **posthereptic neuralgia**. Stop the infusion.
91
What is the MoA of cocaine toxicity?
SNS stimulation by blocking presynaptic uptake of NE and dopamine
| Increases postsynaptic levels
92
What are the adverse effects of cocaine toxicity?
**HTN
Tachycardia
Coronary vasospasm**
MI
Ventricular dysrythmias
**Fetal hypoxemia
Seizures**
93
What are the 4 antiarrythmic drug classes?
Class I - Sodium-channel blockers.
Class II - Beta-blockers.
Class III - Potassium-channel blockers.
Class IV - Calcium-channel blockers.
94
What is the IV dosage of lidocaine?
1 to 2 mg/kg IV (initial bolus) over 2-4 minutes
1 to 2 mg/kg/hour (drip) terminated 12-72 hours
95
What is the easy way to remember what class a LA belongs to?
One "i" in the name means that it is an ester anesthetic (Cocaine)
More than one "i" it is an amide (Lidocaine)
96
What is the molecular structure of lidocaine?
Lipophilic portion (1) connected by a hydrocarbon chain (2) to the hydrophillic portion (3).
**The bond between (1) and (2) classifies it as an ester or an amide**
97
What determines whether or not a local anesthetic is a amide or an ester?
The intermediate chain
98
What is the pH of local anesthetics?
6
Weak bases
99
What four LAs have a potency of 1?
1. P**roc**aine
2. Li**doc**aine
3. Pri**loc**aine
4. **Me**pivicaine
| Roc, Doc, & Loc me in as #1
100
What LAs have a potency of 4?
| *Hint: there are 4*
1. Chloroprocaine (Rapid)
2. **Bupiva**caine (Slow)
3. Levo**bupiva**cine (Slow)
4. Ro**piva**caine (Slow)
| Chlorbupriva came in 4th
101
Which two LAs have a rapid onset?
Chloroprocaine
Lidocaine
| THE REST OF THE LAs ARE SLOW ONSET
102
Which local anesthetic is odd man out in terms of potency?
Tetracaine (16!)
103
What 3 LAs have a duration of 240-480 minutes?
1. Bu**pivacaine**
2. Levobu**pivacaine**
3. Ro**pivacaine**
| It's too far for Mepiva to come here
104
Which LA has the shortest duration time?
Chloroprocaine
30-45 minutes
| Rapid, Potency of 4
105
Which LA has the 2nd shortest duration?
Procaine
45-60 minutes
| potency 1, onset slow
106
Which anesthetics have durations between 60 and 180 minutes?
| *Hint*: There are 4.
Lidocaine (60-120 min)
Prilocaine (60-120 min)
Tetracaine (60-180 min)
Mepivacaine (90 -180 min)
| For the next 60-180 min, I'm your **li**fe p**ilo**t, **t**ip **m**e!
107
Which LAs do not have an toxic plasma concentration?
Ester LAs
| Ester is not a toxic bitch
108
What are the pKs of the ester anesthetics? What are they?
Procaine (pK = **8.9**)
Chloroprocaine (pK = **8.7**)
Tetracaine (pK = **8.5**)
| Each pK drops by 0.2! (PCT!!)
109
Which LAs have a pK in the range of 7?
Lidocaine (**pK = 7.9**)
Prilocaine (**pK = 7.9**)
Mepivacaine (**pK = 7.6**)
| Li, Pri, and Me are on the 7th floor.
110
Which LAs all have an pK of 8.1?
1. Bu**pivacaine**
2. Levobu**pivacaine**
3. Ro**pivacaine**
pK = **8.1**
| Bu, Lev, Ro can **p**ar**k** on **8**, except Mepiva, cuz she's a bitch
111
What are the properties of nonionized drugs?
Faster onset of action
More lipid soluble
Works better
112
What do liposomes do?
**Prolongs duration of action and decreases toxicity of LAs**
Liposomal drug delivery improves the therapeutic efficacy of drugs, reduces side effects, and prolongs drug circulation time in the body.
113
What is the MoA of LAs?
Binds to VG-Na+ channels
Blocks/inhibits Na+ in nerve membranes
114
What 3 factors affect motor blockade?
1. Lipid solubility
2. Repetitively stimulated nerve
3. Diameter of the nerve
115
What are other target action sites of LAs besides VG-Na+ channels?
1. K+ channels
2. Ca2+ channels
3. GPCRs
116
What is MEC?
**Minimum Effective Concentration**
Similar to MAC for VAs, but for LAs
117
How many nodes of ranvier do we need to block?
At least 2, preferably 3 (1 cm)
118
Which nerve fibers are blocked first by a LAs?
Myelinated preganglionic B fibers (SNS)
119
What nerve fibers are second to be blocked by LAs?
Small and medium sized myelinated A and B
120
What determines a LA's intrinsic vasodilator activity?
Potency and DoA
| Lidocaine = greater systemic absorption
121
What effect does the pKa being closer to physiologic pH have on LAs?
More rapid onset
122
What percentage of LAs are lipid soluble in nonionized form?
50%
**LAs are weak bases with pKa values above physiologic pH**
123
What does adding epi to our LAs do?
Increases duration of action
124
What is the primary determinant of potency?
Lipid solubility
125
The rate of clearance for LAs depends on what two factors?
1. Cardiac Output
2. Protein binding: **% bound is inversely related to % plasma**
126
How are esters metabolized?
Hydrolysis by cholinesterase enzyme in plasma
| Except cocaine by the liver
127
What is the primary metabolite of an ester LA?
Para-aminobenzoic acid (PABA)
128
How are amides metabolized?
Microsomal enzymes in the liver
1. Most rapid: Prilocaine (Primary)
2. Intermediate: Lidocaine & Mepivacaine (IdMediate)
3. Slowest: Etidocaine, bupivacaine & ropivacaine (ERB)
129
What two things need to be kept in mind with pregnant patients?
Lower levels of cholinesterases
Significant transplacental transfer (Ion trapping)
*mostly occurs with amides*
130
Which LAs undergo first pass pulmonary extraction?
Lidocaine
Bupivacaine
Prilocaine
| LiBuri
131
Which LA is most protein bound? Least?
1. Bupivacaine (**95%**)
2. Lidocane (**70%**)
3. Prilocaine (**55%**)
**Protein binding and arterial concentration are inversely related**
| Protein Butt Lipper
132
What is the maximum infiltration dose of lidocaine?
300 mgs plain and 500 mgs with Epi
133
What is the metabolite of lidocaine?
Xylidide
134
How is lidocaine metabolized?
Oxidative dealkylation in the liver, then hydrolysis
135
What is the metabolite of prilocaine? What's important to note about it?
Orthotoluidine
**Converts Hgb into metHgb**
136
# What LA is this?
Similar to Lidocaine, except with:
Longer duration of action
Lacks vasodilator activity
Prolonged elimination in fetus & newborn; no OB
Mepivacaine
137
# What LA is this?
Metabolism: **aromatic hydroxylation**, **N-dealkylation**, amide hydrolysis, and conjugation
Protein (95%) binding site: α1-Acid glycoprotein
Bupivacaine
138
# What LA is this?
Metabolism: Liver
MOA: inhibits the activity of normal butyrylcholinesterase (plasma cholinesterase) by more than 70%
Dibucaine
138
# What LA is this?
Metabolism: Hepatic **cytochrome P450** enzymes
Metabolites: can accumulate with **uremic patients**
Lesser system toxicity than Bupivacaine
Protein Binding: α1-acid glycoprotein
Ropivacaine
139
# What LA is this?
Metabolism: Plasma cholinesterase (3.5x faster)
Pregnancy decreases plasma cholinesterase by 40%
Chloroprocaine
140
# What LA is this?
Metabolite: PABA, excreted unchanged in urine
Procaine
141
# What LA is this?
Metabolism: Slower than procaine
Tetracaine
142
# What LA is this?
**Unique: Weak acid (pKa 3.5)**
Uses: **Topical anesthesia** of mucous membranes:
Tracheal intubation, Endoscopy, Transesophageal echocardiography (TEE), Bronchoscopy
Onset: rapid
Duration: 30 to 60 minutes
Dose: Brief spray (20%) = 200 to 300 mgs
**Methemoglobinemia**
Benzocaine
143
# What LA is this?
Metabolism: Plasma and liver cholinesterases
Decreased in: **Parturients, Neonates, Elderly, Severe Hepatic Disease**
Peak: 30 to 45 mins
Duration: 60 minutes after peak
Elimination: Urine (24 to 36 hours)
Caution: **Coronary vasospasm**, ventricular dysrhythmias, HTN, tachycardia, CAD
Cocaine
144
What is the maximum dose of methylene blue in mgs for a 120 lbs patient?
| Divide by 2, subtract 10% for lbs to kg
145
What does alkalinization of LAs do?
**Increases % of lipid soluble or non-ionized form**
Enhances depth
Increases spread
Faster onset
146
# What LA adjuvant is this?
Increased duration of:
Both **motor and sensory blocks**
**First analgesic** request **after spinal** anesthesia
Dexmedetomidine
147
# What LA adjuvant is this?
Increased duration with subarachnoid block with or without opioids.
Magnesium
148
# What LA adjuvant is this?
Prolongs pediatric regional anesthesia duration.
Clonidine & Ketamine
149
# What LA adjuvant is this?
Increased duration either IV or mixed with LA.
Dexamethasone
150
The __________ of a LA is _________ to the time the drug is in contact with nerve fibers
DoA; Proportional
151
Toxic effects are _______
additive
152
# Epinephrine as an additive
1:200,000
1,000,000 / 200,000
**5 mcg/mL**
153
# Epinephrine as an additive
1:500,000
1,000,000 / 500,000
**2 mcg/mL**
154
# Epinephrine as an additive
1:10,000
1,000,000 / 10,000
**100 mcg/mL**
155
# Epinephrine as an additive
1:1,000
1,000,000 / 1,000
**1000 mcg/mL or 1 mg/mL**
156
# Local Anesthetic Strengths
0.25%
2.5 mgs/mL
157
# Local Anesthetic Strengths
0.5%
5 mgs/mL
158
# Local Anesthetic Strengths
1%
10 mgs/mL
159
# What is the dose of this anesthetic
2%
20 mgs/mL
160
# Local Anesthetic Strengths
4%
40 mgs/mL
161
What are the total mgs for bupivacaine and the total mcgs for epinephrine if the surgeon injects 20 mLs of 0.25% bupivacaine with 1:200,000 of epi?
2.5 mgs/mL bupivacaine x 20 mLs = 50 mgs
5 mcg/mL x 20 mLs = 100 mcg
162
What is the dosage of **bupivacaine** with and without epi for **infiltration, PNB, epidurals, and spinals**?
175 mg alone or 225 mg with epi
163
What is the dose for lidocaine with or without epi?
300 mgs alone or 500 mgs with epi
164
What are the 3 clinical uses for lidocaine **with** epinephrine?
1. Infiltration
2. PNB
3. Epidural
165
What is the dose for lidocaine in a spinal?
100 mgs
166
Which three clinical uses for lidocaine is epinephrine **not** added?
Topical, IV regional anesthesia, and Spinals
167
112.5 mgs of bupivacaine with epi and 250 mgs of lidocaine with epi were given during a case. What are the percentages of each local anesthetic based on the recommended maximum single dose in mgs?
This is 50% max of both local anesthetics.
50 + 50 = 100
No more can be given.
168
Where can topical anesthesia be applied?
Mucus membranes of nose, mouth, tracheobronchial tree, esophagus, or GU tract
169
What is the topical dosage of cocaine, tetracaine, and lidocaine?
Cocaine (4% to 10%) > Lidocaine (2% to 4%), Tetracaine (1% to 2%)
| Cocaine causes localized vasoconstriction
170
What is the order of effect for peripheral nerve block?
1. Proximal affected first and then distal
2. Proximal comes back first and then distal
3. **Smallest sensory and ANS fibers first, and then larger motor and proprioceptive axons**
171
What's different about using topical lidocaine over topical cocaine in the tracheobronchial tree?
Inhalation of lidocaine does not alter airway resistance, but it does cause **vasodilation**
172
What's important to know about transtracheal lidocaine anesthesia?
Squirt all of it at once. Do **not** squirt as you withdraw.
173
What is EMLA?
Eutectic Mixture of LA
**Lidocaine and Prilocaine** 2.5% = 5% LA
**Dose 1 to 2 grams/10 cm2 area**
| Do not use with skin wounds, beware of methemoglobinemia
174
IV injection of a LA into an extremity isolated from the rest of the systemic circulation with a tourniquet
**Sensation and muscle tone dependent on tourniquet**
Bier Block
175
Produced by direct injection of LA into **subarachnoid**
**CSF is confirmation**
Preganglionic fibers: Principal site of action
Sensory effect is on **same level** of denervation
Spinal Anesthesia Block
176
SNS is 2 spinal segments ______ of sensory
Cephalad
177
Motor is 2 spinal segments below ______
sensory
178
How do we dose subarachnoid blocks?
1. Height of patient
2. Segmental level of anesthesia desired
3. Duration of anesthesia desired
179
What is important for determining the spread of a local anesthetic in the CSF?
Specific gravity
180
_____ is more important than the concentration of the drug or the volume of the solution injected with subarachnoid blocks
dose
181
What two drugs are used in tumescent liposuction? What are their doses?
Epi and Lido; 1:100,000 that is highly diluted with 35-55 mg/kg of lidocaine tumescent
182
What is the dose for glycopyrrolate?
7-15 mcg/kg (1 mg max)
183
What is the **onset** of NDNMB in order from **fastest to slowest**?
1. Rocuronium
2. Vecuronium
3. Pancuronium
4. Atracurium
5. Mivacurium
6. Cisatracurium
| **RV** **P**ack **A**ll **M**i **C**amping gear
## Footnote
RV pack all my camping gear
184
The closer the pKa is to pH...
50:50; Ionized:Nonionized
185
What are the ester anesthetics?
Procaine (pK = 8.9)
Chloroprocaine (pK = 8.7)
Cocaine
Benzocaine
Tetracaine (pK = 8.5)
| Ester is a PCCT
186
What is the dosage of sugammadex for an extreme block?
8 to 16 mg/kg
187
What is the dosage of sugammadex for a deep block?
4 mg/kg
188
What is the dosage of sugammadex for a moderate block?
2 mg/kg
189
What are the 5 factors influencing NMBD reversal?
1. Intensity of the block
2. NMBD used
3. Continued volatile anesthetic
4. Reversal drug used
5. Patient conditions (acidotic, hypothermic)
190
What type of bond interactions or forces does sugammadex use?
1. Intermolecular (Van Der Waals) forces
2. Thermodynamic (Hydrogen) Bonds
3. Hydrophobic interactions
191
What was the first local anesthetic?
Cocaine
192
What were the first synthetic ester and amide anesthetics?
Procaine; Lidocaine
193
Which anesthetic is the standard to which all others are compared?
Lidocaine
194
What 3 systems are carefully monitored with IV lidocaine?
1. Cardiac
2. Hepatic
3. Renal
195
What anesthetics can utilize liposomes?
1. Bupivacaine
2. Lidocaine
3. Tetracaine
| BLT are fatty
196
What is Exparel?
Bupivacaine ER
Liposomes containing bupivacaine
Lasts up to 96 hours
197
What anesthetics do not have a significant amount of transplacental transfer?
Esters
198
Which amide(s) are most rapidly metabolized?
Prilocaine
199
Which amides are intermediately metabolized?
1. Lidocaine
2. Mepivacaine
| idermediate
200
What amides have the slowest metabolism?
1. Etidocaine
2. Ropivacaine
3. Bupivacaine
| ERB
201
What is the peak and duration of cocaine?
Peak: 30-45 minutes
Duration: 60 minutes after peak
202
What is the average pKa of LAs?
8
203
Alkalinization improves the onset of action in peripheral and epidural blocks by how much time?
3 to 5 minutes
204
What effect do vasoconstrictors have on the rate of onset for LAs?
No effect
205
_______ effects may have some degree of analgesia
a-adrenergic
206
What is the purpose of using topical cocaine?
Cocaine causes localized vasoconstriction which:
1. Decreases blood loss
2. Improves surgical visualization
207
What is EMLA contraindicated with?
Amide allergies
208
Achieved by LA injection into tissues surrounding individual peripheral nerves or nerve plexuses
Peripheral Nerve Block
209
What is the MoA for a PNB?
Diffusion from the outer mantle to the central core of nerve along a concentration gradient
210
What is the point of a eutectic mixture?
Improves the solublity of drugs by combining them
211
How long does it take before you can do skin grafting with a eutectic mixture?
2 hours
212
How long does it take before you can do **cautery of genital warts, venipicture, lumbar puncture, arterial cannulation, and myringotomy** with a eutectic mixture?
10 minutes
213
# In peripheral nerve blocks...
Duration depends on
dose of local anesthetic
214
# In peripheral nerve blocks...
onset depends on?
pK of the local anesthetic
215
What are the 4 examples of PNBs provided by Castillo?
1. Interscalene
2. Axiallary
3. Femoral
4. Sciatic
216
What LA is most commonly used in a Bier block?
Lidocaine
217
What are the steps of a bier block?
1. IV start
2. Exsanguination
3. Double cuff
4. LA injection
5. IV D/C
218
What is the blockade sequence in neuraxial anesthesia?
1. SNS
2. Sensory
3. Motor
219
What confirms a spinal anesthesia block (SAB)?
CSF
220
What is the principal site of action for a SAB?
Preganglionic fibers
221
What is the most commonly used anesthetic in epidural anesthesia?
Lidocaine
222
When will the epidural have an effect on the fetus?
24 to 48 hours
223
What is the normal onset of an epidural?
15 to 30 minutes
224
What component of the local anesthetic is required for a conduction block?
Non-ionized form
225
# True or False
In general, the more lipid soluble the local anesthetic is, the greater its potency.
True
226
Which local anesthetic property is **most** important when it comes to **duration of action**?
protein binding
227
What four things can affect duration of action?
1. Protein binding
2. Lipid solubility
3. Metabolism
4. Clearance
228
What is more acceptable as an additive to both epidurals and SABs?
Opioids
229
What is one of the differences between epidurals and SAB?
No differential zone of SNS
230
In a SAB, 5 ft is equal to _____
1 mL
231
In SAB, for every inch above 5ft you add
0.1 mL
232
How many people will have an allergic reaction from a LA?
Very rare
<1%
233
What anesthetics cause more allergic reactions?
Esters
234
What promotes seizures with LAs?
Hyperkalemia
235
What is the duration of rocuronium?
35 to 75 minutes
236
What peripheral nerves are myelinated?
A-a
A-b
A-gamma
A-delta
B
237
What peripheral nerve fibers have a sensitivity of 1 to procaine?
A-a
A-b
A-gamma
238
# What peripheral nerve fiber is this?
Innervation of skeletal muscles
Proprioception
A-alpha
239
# What peripheral nerve fiber is this?
Touch
Pressure
A-beta
240
# What peripheral nerve fiber is this?
Skeletal muscle tone
A-gamma
241
# What peripheral nerve fiber is this?
Fast pain
Touch
Temperature
A-delta
242
# What peripheral nerve fiber is this?
Preganglionic autonomic fibers
B
243
# What peripheral nerve fiber is this?
Slow Pain
Touch
Temperature
Postganglionic sympathetic fibers
C
244
What peripheral nerve fiber(s) have a 0.5 sensitivity to procaine?
A-delta
C
245
What peripheral nerve fiber(s) have a 0.5 sensitivity to procaine?
B
246
What is the duration of action of all the muscle relaxants from shortest to longest?
1. Succinylcholine (5-10 min
2. Rocuronium (35-75 min)
3. Cisatracurium (40-75 min)
4. Vecuronium (45-90 min)
5. Pancuronium (60-120 min)
| **SR or MR CVP**
247
What are the pKs of Lidocaine, Prilocaine, and Mepivacaine?
Lidocaine (pK = 7.9)
Prilocaine (pK = 7.9)
Mepivacaine (pK = 7.6)
248
What anesthetics have pKs above 8?
Bupivacaine (pK = **8.1**)
Levobupivacaine (pK = **8.1**)
Ropivacaine (pK = **8.1**)
Procaine (pK = **8.9**)
Chloroprocaine (pK = **8.7**)
Tetracaine (pK = **8.5**)
| ALL EXCEPT Li, Pri, & Me
249
What are the pKs of Lidocaine, Prilocaine, and Mepivacaine?
Lidocaine (pK = 7.9)
Prilocaine (pK = 7.9)
Mepivacaine (pK = 7.6)
| Li, Pri, and Me are on the 7th floor
250
How long does MetHgb reversal take after giving methylene blue?
20-60 minutes
251
What's another possible reversal for mivacurium?
Purified human plasma cholinesterase
252
What is toremifene? What's important to know about it?
Non-steroidal anti-estrogen
Can displace NDMB from sugammadex
253
Protein binding is equal to....
rate and degree of diffusion
254
How much 8.4% NaHCO3- is added to 30 mL of LA?
1 mL
255
Which combination of LAs has a rapid onset and tachyphylaxis
Chloroprocaine and Bupivacaine
256
What is the dose for regional anesthesia with lidocaine and epineprhine?
7 mg/kg
257
What is the tissue buffering system?
1 gm SQ tissue can absorb up to 1 mg of lidocaine
258
What is the plasma peak s/p injection?
12-14 hours
259
How much SQ infiltration can occur with tumescent liposuction?
5 L
260
Glycopyrrolate is administered slowly over....
2-5 minutes
261
Which type of medication is given first during reversal?
Anti ACh drug
262
Sugammadex is contraindicated in...
patients on dialysis
263
What NMBD are not reversed by sugammadex?
1. Atracurium
2. Mivacurium
3. Cisatracurium
| AMC
264
How much epinephrine do you give with intralipid therapy?
10 to 100 mcg
265
What are the predisposing factors for cardiovascular system effects with LAs?
1. Pregnancy
2. Arterial hypoxemia
3. Beta blocker, digitalis, Ca2+ (cardiac drugs)
4. Epinephrine & Phenylephrine
266
How long is the recovery time from TNS?
1 to 7 days
267
What is the order of lipid solubility of lowest to highest?
1. Procaine
2. Prilocaine
3. Mepivacaine
4. Lidocaine
5. Bupivacine
6. Tetracaine
| Pro Players Major League Baseball Tall
268
What is the order of protein binding (%) from lowest to highest
1. Procaine
2. Prilocaine
3. Lidocaine
4. Tetracaine
5. Mepivacaine
6. Ropivacaine
7. Bupivacaine
8. Levopbupivacaine
| **PPL** **T**ell **MR** **B L**ies about protein binding
269
What nerve fibers are last to be blocked by LAs?
C
270
Which populations have decreased plasma cholinesterases????
1. old people
2. neonates
3. pregnant people
4. severe hepatic disease
