reversal of benzo and opioid

Question 1

Benzodiazepine antagonist

Answer 1

Flumazenil (Romazicon)

Question 2

MOA of flumazenil - romazicon

Answer 2

Competes with benzodiazepines for the benzodiazepine receptor sites on GABA receptors

Question 3

Flumazenil (Romazicon) reverses [if given right]

Answer 3

the respiratory depressant effect of benzodiazepines

Question 4

you have a pt that has exhaled all volatiles but is still showing signs of delayed emergence, what are you going to give?

Answer 4

flumazenil first then narcan

Question 5

the Reversal of benzodiazepine effects from Flumazenil is buffered by

Answer 5

the weak agonist effect

Question 6

Do NOT see these effects with flumazenil admin

Answer 6

Acute anxiety, stress response

Hypertension, tachycardia

Question 7

Could see this effect from flumazenil admin

Answer 7

Withdrawal seizures for those on sz. treatment

Question 8

what is the initial dose and how do you dose romazicon after intial?

Answer 8

initial - 0.2 mg IV then 0.1 mg IV every 60 seconds up to 1 mg

Question 9

onset of flumazenil?

Answer 9

2 minutes [give it time to work before redosing]

Question 10

duration of flumazenil?

Answer 10

30-60 minutes

Question 11

amount of flumazenil you need to give to decrease sedation?

Answer 11

0.3-0.6 mg

Question 12

amount of flumazenil you need to give to abolish benzo effect

Answer 12

0.5-1 mg

Question 13

important thing to note about redosing flumazenil and narcan?

Answer 13

both have shorter duration than drug trying to reverse so tell RN that you had to give it so they are aware

Question 14

what receptors does narcan effect more

Answer 14

mu more than kappa and delta

Question 15

competitive opioid antagonist

Answer 15

naloxone - narcan

Question 16

MOA of narcan

Answer 16

The attraction of naloxone for the receptor displaces the opioid from the receptor. The antagonist then binds with the receptor and inactivates it.

Question 17

Clinical indications for the use of naloxone (4)

Answer 17

1. Opioid overdose – deliberate or mistaken
2. Postoperative ventilatory depression due to opioids
3. Neonatal ventilatory depression due to maternal opioids (10 mcg/kg q 2 minutes)
4. Adverse effects of spinal and epidural opioids

Question 18

Dose of narcan

Answer 18

0.5-1 mcg/kg (35-70 mcg) q 3-5 min

Question 19

what do you need to do in order to make narcan easier to give?

Answer 19

Dilute 0.4 mg/ml into 10 cc to get 40 mcg/ml (0.04 mg/ml)

Question 20

onset and duration of naloxone?

Answer 20

onset - 1-3 mins

duration - 30 to 45 mins

Question 21

metabolism of narcan

Answer 21

liver

Question 22

what is the weird effect that narcan can have and why?

Answer 22

Acute pulmonary edema can be caused by the increase in pressure [sympathetic stimulation] and increased permeability of pulmonary capillaries.

Question 23

Cardiovascular effects naloxone?

Answer 23

Sympathetic stimulation - PAIN
Tachycardia, ventricular irritability (V fib)
Hypertension
Related to speed and extent of reversal

Question 24

CNS effects narcan?

Answer 24

Nausea and vomiting (speed, dose)

Return of airway reflexes which is good but can be bad if it causes laryngospasm

Question 25

does narcan cross placenta?

Answer 25

YES may cause withdrawal symptoms if opioid-abusing mother

Question 26

what can narcan precipitate in pts who appear normal on opioids?

Answer 26

withdrawals [aka abstinence syndrome]

Question 27

What pt populations should you be careful or avoid narcan with?

Answer 27

``` Critically ill Coronary artery disease Preexisting lung disease Congestive heart failure Cardiac surgery Opioid dependence *sympathetic stimulation* ```

Question 28

Central nervous system stimulant

Answer 28

doxapram - dopram

Question 29

MOA doxapram

Answer 29

Stimulates hypoxic drive via the activation of the chemoreceptors in the carotid bodies (1 mg/kg = PaO2 of 38 mm Hg) basically tricks the body into thinking we need to blow off some CO2

Question 30

doxapram Produces an increase

Answer 30

tidal volume and RR. will see an increase in minute vent r/t the increase in tidal volume

Question 31

Clinical indications for doxapram

Answer 31

- delayed emergence r/t not being able to get volatile out of lungs bc pt isn't breathing - COPD - vent depression and CNS depression due to other meds

Question 32

what two examples of patients are appropriate for doxapram use?

Answer 32

rigid bronchoscopy | airway case with high prop infusion that you can't give NMB to so you need to make them breath

Question 33

dose of doxapram?

Answer 33

0.5-1 mg/kg (max 4 mg/kg)

Question 34

onset duration metabolism of doxapram

Answer 34

Onset: 1 minute Duration: 5-10 minutes Metabolism: primarily in the liver

Question 35

CNS effects of doxapram

Answer 35

- Stimulates hypoxic drive due to activation of chemoreceptors in the carotid - Mental status changes like confusion, dizziness, seizures (20-40X dose) - Increased sympathetic outflow (increase HR, BP) - Vomiting - Increased body temperature

Question 36

Respiratory effects of doxapram

Answer 36

- Increases minute volume by increasing tidal volume and slightly increasing respiratory rate - Increases oxygen consumption - Wheezing - bronchoconstriction - Tachypnea

Question 37

cards effects of doxapram?

Answer 37

Increased sympathetic stimulation Hypertension Tachycardia Cardiac dysrhythmias