Special Populations

Question 1

Aging patients (3 facts)

Answer 1

1. fastest growing population
2. have less organ reserve
3. more prone to adverse reactions

Question 2

Aging patients hemodynamics (3 facts)

Answer 2

1. volume dependent b/c LV hypertrophy (LVEDP increased)
2. endogenously blocked (beta)
3. stiff lungs

Question 3

Pharmacokinetic Changes in Elderly

Answer 3

1. Body water decreases (60 —-> 50%)
2. Serum Albumin decreases (4.7 —-> 3.8)
3. Kidney weight decreases (80%)
4. Hepatic blood flow decreases (55%)

Question 4

Elderly & opioids (2)

Answer 4

brains are very sensitive - watch out - use BIS

dosage is inversely r/t patient’s age and essentially independent of body size

Question 5

Age-related dose reductions for IV medications (6)

Answer 5

1. Longer 1/2 lifes
2. 30% decrease dose/10 years
3. increased brain sensitivity to narcotics
4. Plasma drug concentrations immediately post injection are higher
5. CYP450 enzymes are maintained
6. Plasma cholinesterase decreases in elderly (male)

Question 6

Regional anesthesia & elderly (5)

Answer 6

1. Anatomic changes in epidural/subarachnoid space
2. Diameter and number of myelinated fibers is decreased
3. Increased permeability of dura & decreased volume of CSF
4. Occlusion of foramina w/fibrous CT (patchy block)
5. With a fixed dose & volume of LA, spread of block is higher in the elderly

Question 7

Muscle relaxants & elderly (5)

Answer 7

1. onset of action is delayed
2. they have less muscle mass
3. DOA extended
4. antagonism is unchanged
5. reduced plasma cholinesterase
   * increase dose of NMBD or keep the same*

Question 8

Postop Delirium (cause; onset)

Answer 8

occurs 1-3 days postop; inflammatory process

Question 9

What drugs to avoid in elderly?

Answer 9

1. meperidine
2. antihistamines/anticholinergics
3. adjust renal meds

Question 10

Drugs w/anticholinergic properties

Answer 10

TCA
Antihistamine
Antimuscarinic
Antispasmodic
1st gen antipsychotics
H2 antagonists (cimetidine, ranitidine)
Skeletal muscle relaxants 
Antiemetics (promethazine)

Question 11

Drugs that induce POD

Answer 11

anticholinergics
steroids
meperidine
sedative hypnotics
polypharmacy

Question 12

Some other stuff about oldies (3)

Answer 12

1. Renal impairment
2. Decreased plasma protein
3. Reduced gastric motility and acidity

Question 13

Obese pt - pharmacology significantly influenced by ??

Answer 13

1. tissue
2. hemodynamics
3. blood flow
4. plasma composition
5. liver/kidney function

Question 14

PK factors & obesity

Answer 14

lipid solubility

diffusion through compartments

Question 15

Dosing for obese patients (3)

Answer 15

1. Vd (IBW for drugs to lean tissue, TBW for drugs w/equal distribution to lean/adipose tissue)
2. clearance
3. LBW - extremely obese pt create more muscle weight….

Question 16

Thiopental & obese

Answer 16

TBW

prolonged duration of action

Question 17

Propofol & obese

Answer 17

LBW for induction
TBW for maintenance
highly lipophilic- total clearance and VD correlate well w/TBW

Question 18

Midazolam & obese

Answer 18

Loading dose TBW
Maintenance IBW
higher dose to achieve initial therapeutic effects

Question 19

Dexmedetomidine & obese

Answer 19

0. 2 mcg/kg/m

* lower than usual infusion rates recommended to decrease cardiac S/E*

Question 20

Succinylcholine & Obese

Answer 20

TBW

large ECF compartment in the obese; pseudocholinesterase activity increases w/weight

Question 21

Roc/Vec/Cis & obese

Answer 21

IBW

Question 22

Fentanyl & obese

Answer 22

??? IBW ???

Question 23

sufentanil & obese

Answer 23

loading dose: TBW

Maintenance: LBW (increased 1/2 life w/prolonged elimination)

Question 24

pediatric rectal

Answer 24

rectal: slower, used for < 5 y.o.

Question 25

pediatrac intranasal

Answer 25

faster; midaz & fent

Question 26

pediatric IM

Answer 26

not recommended d/t pain for days

Question 27

pediatric IV (3)

Answer 27

DEPENDENT ON 1. circulating blood elements 2. blood/tissue partition 3. distribution of blood flow

Question 28

what are the two major proteins involved in binding drugs

Answer 28

1. albumin 2. alpha 1 acid glycoprotein *MUCH LOWER IN INFANTS*

Question 29

muscle mass & fat in the infant

Answer 29

less muscle mass; greater fat stores

Question 30

blood flow to central organs in infant

Answer 30

greater

Question 31

succinylcholine dose in peds

Answer 31

higher (all water soluble drugs may require higher doses)

Question 32

CO in the infant

Answer 32

HIGH (400 ml/kg/m)

Question 33

GFR at birth

Answer 33

40 mL/m

Question 34

GFR at 1-2yr

Answer 34

100 mL/m

Question 35

G1

Answer 35

cell growth checkpoint (at the end of growth phase G1) checks if cell is big enough/right proteins goes to G0 if not ready

Question 36

S phase

Answer 36

DNA synthesis checkpoint

Question 37

G2 --> M

Answer 37

``` M phase (mitosis checkpoint) makes sure mitosis is complete before dividing ```

Question 38

Cisplatin

Answer 38

nephrotoxicity, neuropathy, nerve dysfunction

Question 39

Methotrexate

Answer 39

myelosuppression, neutropenia & thrombocytopenia

Question 40

Bleomycin

Answer 40

hodgkins/non-hodgkins | -pulmonary fibrosis

Question 41

Doxorubicin

Answer 41

cardiotoxicity, myelosuppression

Question 42

Cetuximab

Answer 42

interstitial lung disease

Question 43

Volatiles, barbs, ketamine

Answer 43

SUPPRESS NK CELL ACTIVITY - promote cancer

Question 44

Nitrous oxide

Answer 44

SUPPRESS NEUTROPHIL - promote cancer

Question 45

Propofol

Answer 45

protective effects - activates helper T cells; antimetastatic

Question 46

Opioids

Answer 46

immunosuppression especially morphine

Question 47

LA

Answer 47

reduce metastatic burden

Question 48

GA on CA patients

Answer 48

immunosuppresion, decreasing HPA axis, hypothermia

Question 49

Drugs good for CA patients

Answer 49

``` propofol LA BB NSAIDS Naltrexone ```