TDRD Flashcards

Question

Reactions- drugs that cause anaphylaxis reactions

Answer 1

Under anesthesia what would you see tachycardia, hypotension, bronchospasm – wheezy peak pressure – different than an awake pt. sugammadex (high doses) , rocuronium, antibiotics

Answer 2

Intensity of the block Dose and choice of NMB Drug interactions Choice of reversal agent Disease process (liver failure)

Answer 3

Time, drugs, Hoffman

Answer 4

Acetylcholinesterase : enzyme responsible for rapid hydrolysis of released acetylcholine Reversal of NMB, myasthenia gravis (Diagnosis and treatment), treatment of central anticholinergic syndrome Inhibiting the action of acetylcholinesterase, Increase Ach Unwanted muscarinic stimulation SLUD- salivation, lacrimation, urination, and defecation, which are the clinical signs associated with muscarinic cholinergic overstimulation(I ADDED) Increased bronchial secretions/bronchospasm Bradycardia caused by slowing conduction velocity of the cardiac impulse through the AV node CNS excitement (physostigmine)

Answer 5

Acetylcholinesterase Inhibitors Neostigmine Edrophonium Pyridostigmine Selective Relaxant Binding Agent Sugammadex

Answer 6

10mg 1mg/ml ## Footnote Inhibits hydrolysis of ACh by AChAsE Blocks AChAse at all cholinergic synapses causing parasympathetic effects Used with glycopyrrolate (anticholinergic) to decrease muscarinic side effects of Neostigmine Quaternary ammonium compound therefore does not penetrate the blood-brain barrier (BBB) very well Ceiling effect- 5mg When to Reverse with Neostigmine.. Used in deep blocks Shouldn’t be given until spontaneous recovery evident (TOF) More effective with moderate blocks but slow acting Ceiling effect Because of this ceiling effect Neostigmine can’t effectively antagonize deep blocks Giving more may even worsen it and potentially increase the incidence of residual block 15 mins when at right time? I ad ded Given with Glycopyrrolate- .2mg/ml 5ml vial =1 mg

Answer 7

Used with atropine due to rapid onset Inhibits the destruction of ACh by AChE Enlon-Plus is a mixture of Edrophonium and atropine together in the same vial Rapid onset (1-2 min), short duration Quaternary amine Dose: .5-1 mg/kg mixed with atropine 0.014 mg per 1 mg of edrophonium Enlon-plus: .05-.1 mg/kg slowly over 1 minute Enlon plus!! Is a mixture with atropine\*\*\* Atropine is .4mg/ml 20ml vial? per pic

Answer 8

Excessive stimulation of Ach receptors: either direct stimulation of receptor or inhibition of acetylcholinesterase Overstimulation of nicotinic and muscarinic receptors How: Too much Anticholinesterase, organophosphate poisoning/nerve gas, certain drugs Symptoms: Muscarinic (SLUD), muscle cramping, weakness, decrease BP/HR, CNS (restless, anxiety, confused, seizures, coma) Treatment: Atropine, benzos (versed/valium),Oximes (pralidoxime, obidoxime)

Answer 9

Tertiary amine: only anticholinesterase (acetylcholinesterase inhibitor, cholinesterase inhibitor) that crosses the blood brain barrier Not used for reversal of muscle relaxants Used to treat anticholinergic toxicity S/S: flushing, dry skin and mucous membranes, mydriasis with loss of accommodation, altered mental status, fever and urinary retention CNS: restless, shivers, agitation, disoriented Types of anticholinergics (atropine, scopolamine, antihistamines, antipsychotics, cyclic antidepressants)

Answer 10

Used for reversal of Zemuron/Vecuronium Selective relaxant binding agent that encapsulates rocuronium or vecuronium preventing its action: can reverse profound neuromuscular blockade What’s the dose of Sugammadex? Dosing for Rocuronium and Vecuronium 2 mg/kg TOF of 2 4 mg/kg 1-2 post-tetanic counts (PTC) and no TOF twitches Dosing for Rocuronium only 16 mg/kg to reverse RSI dose of Rocuronium of 1.2 mg/kg after 3 minutes What are the Warnings and Precautions on Sugammadex? Anaphylaxis and Hypersensitivity Bradycardia Risk of coagulopathy and bleeding Increases in PTT and PT, especially in those who were treated with heparin or low molecular weight heparin for thromboprophylaxis Interactions with other drugs (hormonal contraceptives and Toremifene)……… suggest NO sex for 7 days Common adverse reactions: N/V, hypotension, headache

Answer 11

Competitive inhibitors of Ach at parasympathetic muscarinic receptors to increase the heart rate Inhibits salivary, bronchial, and GI secretions Reduces gastric motility Causes bronchodilation Antagonize the muscarinic effects of anticholinesterases used to reverse NDMR

Answer 12

Competitive acetylcholine antagonist at central and peripheral receptors, antimuscarinic, naturally occurring alkaloid Tertiary amine Indications: reversal, brady arrhythmias/vagal stimulation, oculocardia reflex, peritoneal stimulation Careful use in narrow-angle glaucoma Crosses placenta to increase FHR and decrease beat to beat variability in baby Dose: 0.014mg / mg of edrophonium or .2-.4mg for vagal stimulation Onset: \<1 min; duration: up to 30 min Dilating an eye with narrow angle glaucoma closes the angle completely. Medications can worsen both types of glaucoma.

Answer 13

1mg .2mg/ml Synthetic antimuscarinic, competitive Ach antagonist Uses: in combo with Neostigmine for reversal, antisialogogue(xerostomia), increase HR Quaternary ammonium Dose: 0.2 mg per 1 mg Neostigmine Onset: about 1 min IV; 15-30 min IM Duration: 2-4 hours No CNS or mydriasis

Answer 14

.4mg/ml Competitive antagonist of Ach at muscarinic receptors, antagonizes histamine and serotonin Tertiary amine, naturally occurring alkaloid Uses: Decreases secretions, PONV, motion sickness/vertigo, dilate pupils and cycloplegia, unstable trauma pt, sedation/amnesia Toxic psychosis in elderly Effects from restlessness to agitation IM/IV before surgery; transdermal patch (what should we warn them about) Typical dose: 0.3-.5 mg IM or IV Cycloplegia: paralyzing the ciliary muscle and thus the power of accommodation. Crosses BBB – more geared toward motion sickness- different drug with different modes of action for PONV – careful with older pts dilate eyes… Also dry mouth\*\*\*

Answer 15

Overdose of scopolamine and sometimes Atropine(tertiary amines), phenothiazine Signs: anxiety, disoriented, hyperactive, sedation, seizure, mydriasis, increased HR, Atropine flush, dry/flushed skin, atropine fever Can be mistaken for delayed recovery from anesthesia Treat with Physostigmine: tertiary amine that crosses the BBB Dose: 1-2 mg IV and may need to be repeated every 1-2 hours (physostigmine is metabolized rapidly) Muscarinic Antagonist Toxicity Anticholineric toxidrome - pic

Answer 16

Adequate volume Blood TOO MUCH ANESTHESIA

Answer 17

Mixed acting synthetic noncatecholamine sympathomimetic Indirect Effect Ephedrine into Alpha-1 and Beta-1 receptors displaces norepinephrine presynaptic Norepi is released and activates the postsynaptic receptors to cause arterial and venous vasoconstriction and increased myocardial contraction Direct Effect Directly stimulates Beta-2 Increased heart rate, cardiac output and some SVR increase Uses: increase BP/HR, CO and contractility, PONV, bronchodilator effect Used in Obstetrics: can cause fetal tachycardia and acidosis which was associated with lower umbilical artery pH at delivery Contraindicated with MAO inhibitors, Pheochromocytoma Careful use in CAD Tachyphylaxis (depletion of presynaptic norepi) Dose: 5-10 mg at a time to increase BP/HR; Ephedrine 25mg/Vistaril 25 mg IM for antiemetic effect 20 min before end of surgery 50mg 5mg/ml - make by taking 1ml with 9ml of normal saline = 1cc (50 mg) + 9 cc of NS = 5 mg/cc

Answer 18

Directly stimulates alpha-1 receptors, minimal effect on alpha-2 or Beta receptors Uses: hypotension, decrease CO in patients with LV dysfunction Causes constriction of cutaneous, mesenteric, splenic and renal Vasopressor of choice in OB Causes vasoconstriction to increase BP, reflex decrease in HR, increase in coronary blood flow Dose: 50-100 mcg titration to effect 100 mcg/ml 1g in 10ml how to mix = .1 cc (10mg/cc vial) + 9.9 cc NS = 100 mcg/cc

Answer 19

Ephedrine won’t decrease uterine blood flow Some antiemetic property, good for hypotension from regional anesthesia Can cause fetal tachycardia and acidosis Neosynephrine is preferred in OB now Good for hypotension post-regional Faster onset and shorter duration of action Maintains fetal pH

Answer 20

Identify the potentially reversible causes of hypertension! Pain Hypothermia Anxiety Increased ICP Bladder distention Poorly controlled HTN Lack of anesthesia

Answer 21

Nonselective Beta-1 and Beta-2 with selective Alpha-1 adrenergic antagonist, primarily considered a Beta Blocker Uses: acute and chronic HTN in pregnant pts, treat increases in BP and HR from stimulation (intubation) BP reduction causes decreased CO and PVR, can depress cardiac contractility, minimally affects CBP or ICP Contraindicated in bronchospastic disease, impaired cardiac conduction or underlying resting bradycardia Dose: 5-20 mg boluses IV; onset: 1-2 min; duration: up to 6 hours 100mg/20ml 5mg/ml

Answer 22

Rapid-onset and short-acting selective Beta-1 antagonist Uses: treat perioperative tachycardia, pre-treatment during intubation/extubation Decrease in HR, myocardial contractility, CO and some decrease in BP, no rebound effects Contraindicated in bradycardia, heart block, cardiogenic shock and heart failure Dose: 10mg boluses IV, infusions of 50 mcq/kg/min after a .5mg/kg bolus; Onset: rapid; duration: 10-15min Metabolized by plasma esterases 100mg 10mg/ml - fast on fast off

Answer 23

Nonselective Beta-1 and Beta-2 antagonist Uses: HTN, angina, acute MI, pheochromocytoma, treat anxiety and panic attacks Decreases BP due to decrease in myocardial contractility, HR, CO therefore decrease in myocardial oxygen demand Careful use in bronchospastic disease, AV block and bradycardia Dose: 1 mg-3mg IV (no more than 1 mg/min), titrated to effect; onset: around 2-3 min; duration up to 4-6 hours (depending on the source you read) may give Esmolol not working 1mg/ml

Answer 24

Selective B1 adrenergic receptor antagonist, prevents inotropic and chronotropic responses to Beta stimulation Uses: rapid HR and contractility control, CO and therefore decrease BP, treatment for MI Dose: 1-5 mg IV up to 15 mg Half-life of 3-4 hours 5mg 1mg/ml

Answer 25

Antidiuretic hormone, released by the posterior pituitary V1 (CV effects), V2 (renal), V3 (pituitary) receptors Uses: cardiac arrest, sepsis, shock and h**ypotension secondary to ACE inhibitors refractory to catecholamines or sympathomimetics** Dose: I0/20 units/ml in 10/20 ml syringe, 1-2 unit bolus (mix with Saline) Potent vasoconstrictor: arterial and mesenteric I think used in vasoplegia 1unit per ml?

Answer 26

Direct systemic arterial vasodilator causing relaxation of arterial smooth muscle; blocks calcium release from sarcoplasmic reticulum; decreases BP with increase in HR, SV, and cardiac output Uses: HTN, heart failure, Eclampsia Potential for increased ICP, careful/contraindicated in CAD Dose: 2.5-5 mg IV titrated every 20-30 min; onset: 15-30 min; duration: 4-6 hours 20mg/ml pregnant start labetalol then hydralazine then nitroprusside

Answer 27

Postoperative nausea and vomiting (PONV) defined as nausea and/or vomiting within 24 hours of surgery Along with pain, PONV is the highest complaint and leading cause of unanticipated hospital admission after outpatient surgery 40% of patients without prophylaxis have nausea who have general anesthesia 80% of high risk patients without prophylaxis

Answer 28

Patient factors: female(strongest indicator), nonsmoker, hx of PONV and/or motion sickness Surgical factors: longer procedures, certain procedures (GYN, laparoscopy, ENT, Breast/Plastics) Anesthetic factors: inhalationals, nitrous?, neostigmine, opioids Kids: weak association with age, greatest association is the surgical procedure (hernia, tonsils/adenoids/ strabismus surgery, male genitalia) Adults: risk may decrease with age

Answer 29

PONV is associated with: dehydration, electrolyte abnormalities, wound dehiscence, bleeding, airway compromise and UNPLANNED ADMISSIONS and PATIENT DISCOMFORT

Answer 30

Prevention of Motion Induced nausea and PONV Trauma patients Motion sickness is caused by stimulation of the Vestibular apparatus Opioids and morphine increase vestibular sensitivity to motion! Transdermal absorption of scopolamine (sustained plasma concentration) so may have less sedation, cycloplegia and drying of secretions Visual disturbances due to anisocoria (unequal pupil size)

Answer 31

Selective 5-HT3 receptor antagonist in GI tract and Chemoreceptor Trigger Zone Preventative and rescue treatment for N/V, used in chemo Side Effects: headaches, diarrhea Careful use in patients with prolonged QT interval: can lead to torsades Questionable use in Obstetrics Dose: 4 mg IV; duration: 4-6 hours; extensive hepatic metabolism WHEN DO YOU GIVE IT? literature 10 mins before end 4 hrs maybe 2x? 4mg 2mg/ml

Answer 32

Nausea and Vomiting prevention, ENT, traumatic intubations….. Corticosteroid, used in combination with other antiemetics, lowers surgical inflammation, low cost Mechanism is unclear, proposed to centrally inhibit prostaglandin synthesis and control endorphin release Side effects: genital itching/burning (give after patient asleep), hyperglycemia Careful in diabetics, wound healing issues? Dose: 4-12 mg IV on induction; duration about 24 hours 20mg 4mg/ml

Answer 33

Phenothiazine, H1 receptor antagonist (antihistamine), Anticholinergic action (motion sickness), **D2 antagonist in CTZ** Considered a First-generation H1 receptor antagonist due to sedation potential Uses: N/V and anxiety Causes sedation, potentiates sedative effects of benzos and opioids (Cesarean delivery), hypotension, extrapyramidal symptoms (Akathisia) Dose: 12.5-25 mg IV (diluted and given slowly in good IV); onset: 3-5 min; duration: 4-6 hours 50/25mg /ml? dont give to parkinson patient?

Answer 34

Factors associated with pulmonary complications of aspiration: Volume of gastric contents Acidity of the aspirated gastric contents

Answer 35

Gastrointestinal **prokinetic**, increases LES tone, enhances response to AcH in upper GI tract to **enhance gastric motility and accelerate gastric emptying/reducing gastric volume** Antiemetic action probably due antagonism dopamine-agonist effects in the chemoreceptor trigger zone Inhibition of dopamine receptors within the CNS….. Crosses the BBB Can cause sedation, restlessness, extrapyramidal symptoms (tardive dyskinesia) Contraindicated bowel obstructions and Parkinson's, restless leg syndrome, or movement disorders related to dopamine inhibition or depletion What pt would you not give this to- small bowel obstruction… Parkinson, old people\*\*= they can have increase Parkinson make crazy kinda like scpalmine Treatment of diabetic gastroparesis, GERD, OB Usually given in preop for aspiration prophylaxis Does not alter gastric fluid pH Dose: 5-10 mg IV in preop; duration: 1-2 hours; onset: 1-3 minutes, can be used as a rescue drug in PACU Potential for Neuroleptic Malignant Syndrome What is NMS? How is it treated? What other syndrome is it similar to? 10mg 5mg/ml RSI, Trauma, pego, bad reflux – aspiration prophylaxis only moves things but does not help with gastric ph

Answer 36

H2- receptor antagonist, inhibits gastric acid secretion/fluid volume and raises gastric pH Given in preop to decrease risk of pulmonary aspiration in at risk patients Dose: 20 mg IV Onset: 30 min – 1 hour 20mg 10mg/ml

Answer 37

Blocks Ach in the vestibular apparatus, blocks H1 receptors in the solitary tract, antihistamine Uses: N/V, pruritus (pregnancy), antianxiety Side effects: sedation, pain on injection Dose: 25 mg mixed with Ephedrine 25 mg IM 20 minutes before the end of surgery (careful in HTN patients/outpatients) 100mg 50mg/ml

Answer 38

Uses: induction of labor and control postpartum uterine bleeding, after Suction D&C Indirectly increases intracellular calcium, directly stimulates the oxytocin receptor on the myometrium, some antidiuretic Contraindicated in: fetal distress, unfavorable fetal positions, previous uterine rupture Effects: flushing, brady/tachycardia, hyper/Hypotension Dose: 10-40 U in 1000cc LR; onset: immediate; duration: within 1 hour PRESSOR EFFECTS? We never give IV\*

Answer 39

Semisynthetic ergot alkaloid, increases motor activity of uterus by acting directly on smooth muscle to increase tone, rate and amplitude of contraction Arterial vasoconstriction by alpha stimulation, inhibition of endothelial derived relaxation factor release Contraindications: severe HTN, PIH and cardiac disease Dose: 0.2 mg IM every 2-4 hours (max 5 doses); onset: 2-5 min; duration: about 3 hours NEVER IV can raise BP alpha. .2mg/ml

Answer 40

Synthetic analogue of prostaglandin F2 that stimulates uterine contraction, increase of myometrial calcium, stimulates smooth muscle of GI tract to cause diarrhea Increase in temperature possibly due to effect on hypothalamic thermoregulation(can increase 2 degrees) Airway constriction and wheezing, increase CO, BP and PVR (constriction of vascular smooth muscle) Dose: 250 mcq IM repeated every 15-45 min, max 8 doses; onset: immediate; duration: 2 hours 250mcg/ml

Answer 41

Synthetic prostaglandin E1 Indicated for uterine atony, abortions, cervical ripening, peptic ulcer disease Dose: 1-2 tablets buccal (200 mcq each), can be given rectally and vaginally (By OB); onset: rapid; half life is 20-40 min

Answer 42

Used to prevent eclamptic seizures (decrease incidence of seizure by 50 %), stop premature labor (tocolytic) Inhibition of acetylcholine release at NMJ Mild vasodilator that decreases uterine activity to increase uterine blood, dilates liver beds and kidneys to increase function, decrease SVR Potentiates nondepolarizers and depolarizers (probably not enough to alter dose) Can cause pulmonary edema, may be some correlation with chorioamnionitis Dose: 4 grams over 20 min, 2-3 grams/ hour infusion; onset: immediate; duration: 20-30 min with good renal perfusion Monitor magnesium levels, treat magnesium toxicity with calcium gluconate 1 gram over 2 min, fluids, diuresis, O2 Crosses the placenta therefore neonate may show signs of respiratory depression, apnea and decreased tone Mg plasma levels- pic

Answer 43

Labetalol: combined alpha and beta antagonist, rapid onset, few neonatal complications (bradycardia) Hydralazine: potent vasodilator, decrease afterload, decrease peripheral resistance (especially when used with volume repletion), decrease maternal BP and uterine vascular resistance to increase Uterine blood flow Limiting side effects are maternal tachycardia (reflex sympathetic response to direct vasodilation), vomiting, tremors **Nipride:** for acute hypertensive crisis, potent arteriolar dilator, rapid onset and short duration, maternal/fetal cyanide toxicity is a concern, but at low doses 5-10 mcg/kg/min is unlikely **Nitro:** venodilator to decrease cardiac filling pressures by acting on capacitance vessels, may get reflex tachycardia Volume Repletion for severe pre-eclampsia, intravascular repletion can improve the low CO, when right and left cardiac filling pressures normalize, CI improves, maternal HR and SVR decrease, fetal circulation improves

Answer 44

Gabapentinoid Decrease hyperexcitability of dorsal horn neurons caused by tissue damage Modulation of calcium-induced release of glutamate centrally in dorsal horn Activation of descending noradrenergic pathways in the spinal cord and brain 300-600 mg PO preop Careful in old age and low GFR, morbidly obese, OSA Used a lot in chronic pain/neuropathic pain Can increase postoperative sedation

Answer 45

Selective COX-2 inhibitor PO dose of 100-200 mg Associated with increased risk of stroke and MI, worsening of HTN Careful/Avoid in known history of CAD or cerebrovascular disease -I added - COX-1 generates prostaglandins that are involved in the protection of gastrointestinal mucosa, while COX-2 generates prostaglandins that mediate inflammation and pain in sites throughout the body.

Answer 46

Central Acting Skeletal Muscle Relaxant Depresses the CNS leading to relaxation of the muscles Used as an adjunct with other medications Can cause sedation Dose: 1 gram IV slowly over 15-20 minutes Can cause hypotension, bradycardia, and convulsions if given rapidly Should probably be avoided in liver and renal dysfunction also get chills?

Answer 47

NSAID, inhibits cyclooxygenase, preventing thromboxane synthesis, which is necessary for platelet aggregation, inhibits prostaglandin synthesis Non-Selective Cox 1 and Cox 2 inhibitor Uses: decrease pain and cramping, postoperative cesarean delivery, orthopedics, laparoscopy…. Minimal CNS effects, no respiratory depression or sedation Careful in elderly and renal Careful use in elderly, bleeding issues, renal impairment with poor creatinine clearance, ASA allergy, asthma, nasal polyps Decreases narcotic us postop 30 mg Toradol IV = about 10 mg morphine Dose: 15 – 30 mg IV every 6 hours; Onset: 10-30 min; Duration: 4-6 hours; peaks in 1-2 hours Take Home: We use Toradol frequently. Make sure your patient has no relative or absolute contraindication to its use. Always ask the surgeon before administering

Answer 48

-added syndrome of airway inflammation characterized by rhinosinusitis with polyposis, asthma, and nonsteroidal anti-inflammatory drug (NSAID) intolerance. Samter's Triad is usually treated by managing asthma symptoms, taking corticosteroids, and having nasal surgery to remove polyps ## Footnote Also called Aspirin Exacerbated Respiratory Disease (AERD) Chronic condition that includes all three triad features and sensitivity to NSAIDS and ASA Acute reactions to aspirin and NSAIDs can be severe and life threatening Usually diagnosed in adulthood (7-10% of adult) May have respiratory reactions to alcohol and impaired sense of smell

Answer 49

Non-opioid alternative or in combination with other drugs Careful use in hepatic impairment/Acute disease, chronic alcoholism, chronic malnutrition, severe hypovolemia, or severe renal impairment Dose: \>50 Kg dose is 1000 mg IV over 15 min, repeated every 6 hours or 650 mg every 4 hours (Max 4 grams in 24 hour period); \< 50 Kg adult is 15mg/kg every 6 hours not to exceed 3g/day PO in preop

Answer 50

**CALDOLOR must be diluted prior to use. Infusion of the drug product without dilution can cause hemolysis. CALDOLOR should not be given as an IV bolus or IM injection.** **ADVERSE REACTIONS**:The most common adverse reactions are nausea, flatulence, vomiting, headache, hemorrhage and dizziness (\>5%). The most common adverse reactions in pediatric patients are infusion site pain, vomiting, nausea, anemia and headache (≥2%). Max dose: 3200 mg/day (800 mg/6 hours) or 2400 mg (40mg/kg) in Pediatrics less than 17 years old **CONTRAINDICATIONS**CALDOLOR is contraindicated in patients with known hypersensitivity (e.g., anaphylactic reactions and serious skin reactions) to ibuprofen or any components of the drug product, and in patients who have a history of asthma, urticaria, or other allergic-type reactions after taking aspirin or other NSAIDs. **WARNINGS AND PRECAUTIONS**CALDOLOR should be used with caution in patients with known cardiovascular (CV) disease or risk factors for CV disease, a history of peptic ulcer disease and/or GI bleeding, liver disease or symptoms of, hypertension, and heart failure. Avoid use in pregnant women starting at 30 weeks gestation.

Answer 51

Potent Monoamine oxidase inhibitor (MAOI) Interacts with Serotonin reuptake inhibitors (selective and nonselective, SSI/SSRI) and SNRI (serotonin-Norepinephrine)serotonin toxicity Can induce severe, potentially fatal serotonin toxicity (serotonin syndrome) Careful with BLUE ARM syndrome (no cuff) Serotonin Toxicity- pic

Answer 52

Used to Visualize ureters during cystoscopy Intraoperative urologic dye marker Dose: dependent upon practitioners 50-100 mg IV (100 mg/ml) Usually works within 5 minutes Precautions: Bronchial asthma Avoid extravasation

Answer 53

Inactive blue dye routinely given IV during urologic and gynecologic procedures to localize the ureteral orifices Dose: 5 ml (8mg/cc) Can see hypertension due to increased PVR with increased HR Can see Increased BP with reflex decrease in HR On rare occasion can see Hypotension, cardiac arrest and cerebral ischemia

Answer 54

Nitroglycerine Nipride Dobutamine Dopamine Review your opioids (Dilaudid, Fentanyl) Cox-1 and Cox-2 inhibitors (Celebrex) Gabapentin

Answer 55

Remifentanil Esmolol Remimazolam Clevidipine Atracurium (and hofman Etomidate (and hepatic) Cisatracurium- 30% hof and rest nonspecific?

Answer 56

Etomidate and Barbituates, oral contraceptives, and sulfa drugs 5 ps – Porphobilinogen deaminase deficiency; Pain in abdomen; Psychological symptoms; Peripheral neuropathy; Pee abnormality; Precipitated by drugs - Disorder of porphrin enzyme metabolism in liver or bone marrow- they are involved in heme production. If history must avoid barbs and etomidate. Thiopental and methohexital

Answer 57

98% propofol 98-94% benzodiazepine- 94%- Dexmedetomidine 75% Etomidate 20% Ketamine- high lipid solubility

Answer 58

Propofol (receptor agonist) (enhancement of GABA inhibition – maybe central cholinergic transmition NMDA, alpha adrenergic sites) Etomidate (agonist) Benzodiazepines- agonist -central inhibitory neurotransmitter ( increase frequency of opening \* increase chloride conductance- hyperpolarization of membrane incr resistance to stim. ) Barbiturates- gaba a agonist – involves cortical and brainstem GABA inhibitory pathway

Answer 59

Ketamine - antagonist (phencyclidine PCP derivative) (racemic mixture of S and R enantiomers).. also non-NMDA glutamate receptors, Nicotinic receptors, cholinergic recpetors, monoaminergic receptors, Mu, delta, and kappa – opioid receptors, and inhibits neuronal Na+ channels (local anesthetic action) and Ca+ channels (cerebral vasodilation)

Answer 60

Dexmedetomidine- highly selective specific potent a2 adrenergic agonist compared to clonidine 7-8x more selective- dose dependent sedation/analgesia

Answer 61

Propofol Etomidate (propylene glycol) – veno-irritation/ phlebitis Versed does not burn its water soluble but… Lorazepam and diazepam do vein irritant\* propylene glycol Pain on injection - Methohexital

Answer 62

Propofol (depressant, neuroprotective **anticonvulsant** (treat status epilepticus), decrease CMRO2, CBF, and ICP… shortens sz duations (ECT), decrease PONV (10-15 mg IV or 10 micogram/kg/min.) antipruritic effect (10mg) Etomidate- potent vasoconstrictor – reduces CBF, ICP, CMRO2 (myoclonic movements- sz like – use versed/opioid to help**; PROconvulsant**; lowers sz threshold Ketamine- POTENT cerebral vasodilator – _increases CBF 60-80%)_ in normocapnia attenulated with hyperventilation maybe not use increased ICP?? dissociative amnestic state- unconscious – eyes open (nystagmus), maintain spon resp. does not react to pain, prevents hyperalgesia and decrease sensitization to acute pain, acute pain and depression treatment Dexmedetomidine – sedative, anxiolytic, analgesic (spinal cord and brain) pt can follow commands Benzodiazepine- **_ANTICONVULSANT_** , skeletal muscle relaxant (centrally), anxiolysis and sedation, amnesia – Decreaces CMRO, CBF, little effect ICP, upper aireway reflex may decrease and central resp drive. Barbiturates – CNS depressant, neuroprotective, **anticonvulsant**, decreases CMRO2, CBF, ICP (EEG burst suppression thiopental)- loss of consciousness, hypnotic effect- inhibit central excitatory pathway- glutamate via NMDA receptors and acetylcholine _Thiopental- anticonvulsant treat status epilepticus – used induction pt with increased ICP and treats ICP resistant to hyperventilation_- Protects the brain- decreases CBF ICP, CRMO2 – releases histamine from mast cells- **Precipitates with succinylcholine, rocuronium and lidocaine** **_Methohexial (brevital)_** – gold standard for ECT- half-life elimination 4 hours, \***_proconvulsant\*_** activity pain on injection

Answer 63

Propofol- decrease SVR, Stroke volume, and CO systolic and diastolic, decrease sympathetic activity- vaso and venodilation – more so after larger dose (dependent), Etomidate- hemodynamically stable\*\* (cardio, trauma, hypovolemic) no effect on it… Ketamine – SNS stimulant induction dose increases HR and BP MAP CO SVR(good for unstable) OB, careful- cardiac severe right heart dysfunction (increases PVR) (good for hypovolemic but not critically ill/shock\*\* they might drop bp if depleted catecholamine stores. Dexmedetomidine – hypotension and bradycardia because high alpha 2 adrenerreceptor activity- esp children – titrate.. blunt hemodynamic SNS effects laryngoscopy – stability as adjuvant Benzodiazepine- minimal cardio depression, can decrease SVP and BP Barbituates- decreases mean arterial pressure, venous vascular tone, and CO, CV depression

Answer 64

Propofol - Resp depress, potent bronchodilator (intracellular ca+), apnea common, maintence dose- increase RR decrease TV Ketamine- no significant depression of vent. Protects airway reflex, muscarinic receptors can increase secretions( glyco) Broncodilates good\*\* Dexmedetomidine- minimal respiratory depression- bolus reduces minute ventilation Benzodiazepines- minimal resp depression ( reversible with flumazenil) Barbiturates- dose dependent respiratory depression- does not cause bronchodilation

Answer 65

Propofol- pain with injection and propofol infusion syndrome, phenyl nuclus and di-isopropyl sidechain – allergic reactions, also genergic metabisulfite\* sulfite sensitivity. Egg/soy- egg white, carful- CV disease trauma/hypotension/ bleeding PROPOFOL infustion syndrome (PRIS) high doses 4mg/kg/hr over 48 hours – acute refractory brady – asystole, unexplained meta acidocis, high K+, rhabdomyo, hyperlipid, enlarged liver, renal failure, EKG and arrhythmida, cardiomyopathies, skeletal mypo high k+ - critically ill (or peds)…. Etomidate – adrenocortical suppression – inhibit 11-beta-hydroxylase prevents cholesterol to cortisol, PONV, Ketamine- Emergence delirium, 5-30%, greater than 2mg/kg, prevent- midazolam, pharm test included bleeding? Dexmedetomidine- bradycardia (40%) and hypotension can give atropine, ephedrine or volume, also omitting loading dose. Can causse dry mouth/nausea and HTN.. Benzodiazepine – can have anterograde amnesia (OB)

Answer 66

Propofol- liver – inactive and water -soluble metabolytes kidneys excreted- extrahepatic sites of metabolism 30% kidneys and lungs – broken down pts with different comorbid states.. Ketamine- liver – cytochrome P – 450 enzyme- ACTIVE metabolite Noreketamine- (1/3-1/5 as active) Etomidate- PLASMA ESTERASES and liver – excreted kidneys 80% and bile 20% Dexmedetomidine- Rapid hepatic metabolism involving conjugation, n-methylation, hydroxylation- excreted urine and feces- distib 1/2l 6min elim 1/2l 2 hrs… weak inhibitory properties on CYP-450 can increase plasma concentration of opioids Benzodiazepine Versed- rapid redistribution, hepatic metabolism and renal clearance (careful renal liver dysfuction, age, comorbidies) – 1- hydroxymidazolam metabolite high hepatic clearance Diazepam- intermediate duration- metabolites- oxazepam and desmethylidaepam – slow Lorazepam (long acting inactive metabolietes Barbiturates- primary metabolism is hepatic with inactive metabolites excreted in urine and bile

Answer 67

1-2.5 mg/kg 30 sec – unconscious Iv MAC- 25-75 mcg/kg/min TIVA GA – 100-200 mcg/kg/min Concentration 10mg/ml (200mg/20ml) Context sensitive half-life – 8 hours - 40 mins

Answer 68

Initial distribution half-life: 2.7 minutes Redistribution of half-life: 29 minutes Elimination half-life: 3-6 hours Volume of distribution: 2.5-4.5 L/kg Induction dose: 0.2-0.3 mg/kg Usual concentration: 2mg/cc (20mg/10ml)

Answer 69

Onset of IV meds: 30-60 seconds Duration: 10-20 minutes Induction dose: 0.5-2 mg/kg IV 4-5 mg/kg IM ◦ Usual concentrations: 10mg/cc (200mg/20ml)

Answer 70

Dose .5-1 mcg/kg over 10 mins (don’t want brady) Infusion .2-.7 mcg/kg/hr Syringe- 4 mcg/ml (80mcg/20ml)

Answer 71

have many routes- versed (shortest acting) PO IV IM Rectal, intranasally, (50% first pass hepatic ( reversal of benzos- FLUMANZENIL (romazicon) .2 mg iv over 15 seconds redoes 45 seconds if no response… every 1 min can give 4 doses max- does not last as long as the benzo sometimes. ## Footnote Most common- midazolam (versed) children often oral .5mg /kg 30 min before OR.. adult 1-2 mg in preop iv. Its additive. – mild if any vein irritiation Onset of IV meds: 30-60 seconds Duration: 10-20 minutes Induction dose: 0.5-2 mg/kg IV 4-5 mg/kg IM Usual concentrations: 10mg/cc

Answer 72

Oxybarbituates ( primidine center – O2 atom on #2 carbon)- Methohexital Thiobarbiturates (pyrimidine center) replace the O2 with sulfur on #2 carbon – Thiopental Thiopental- long elimination half-life 12 hours Methohexital ◦ Induction dose ◦ 1-2 mg/kg (IV) ◦ 20-30 mg/kg (Rectal) Thiopental ◦ Induction dose ◦ 2.5-5 mg/kg (IV) ◦ In the elderly reduce the dose by 30-35%

Answer 73

CV Succinylcholine – sinus brady, junctional, arrest – more common 2nd dose- children- atropine… action at cardiac muscarinic cholinergic receptors Rocuronium (zemuron)- no effect on BP/ HR Vecuronium (norcruon) – cardiac stable Pancuronium- Vagolytic effects- modest tachycardia – antimuscarinic stimulation- direct sympathomimetic effect- noreepi reduced uptake by adrenergic nerves. Increase HR and CO—sometimes cardiac surgery – high dose opioid counteracted Cisatracurium- no changes CNS SCh - Increased intracranial pressure? Muscular Succinylcholine- Fasciculations- 80-90% if not pretreated with nondepolarizer or NSAID – Myalgias – 50-60%

Answer 74

SCh- malignant hyperthermia/muscular dystrophy- myoglobinuria … raise K+ .5-1 in healthy people… worse in burns, severe abd infection, metabolic acidosis, upreg extrajunctional ACHR (hemiplegia, paraplegia, muscular dystrophies, guillian-barre syndrome, and burns… Risk in children don’t know if undiagnosed muscle- hyper kalemia , rhabdo. Only emergency increased gastric pressure? Lower esophagial tone? Increased introcular pressure? I Vecuronium (norcuron)- might precipitate with thiopental

Answer 75

Mivacurium (Mivacron) – profound histamine release- give slow Atracurium (tracrium)- some release- flush tachycardia hypotension Rocuronium – rare Vecuronium – no histamine Pancuronium (Pavulon)- no histamine Cisatracurium- no release

Answer 76

Vecuronium- not bad one but – 3-desacetyl – 60% potent Pancuronium- need to know 3-OH pancuronium- it is 50% potency and worried about the vagolytic effect get tachycardia Atracurium (tracrium) Laudanosine- rare seizure activity- tertiary amine – CNS stimulant Benzylisoquinolines – hofmann elimination – no organ or enzyme needed temp and ph dependent increase increase metabolism. Mivacurium- hydrolysis by plasma cholinesterase Atracurium metabolism- same enzymes for esmolol and remifentanil – hofmann elminiation 30% and ester hydrolysis for 60% Cisatracurium – 30% hofmann metabolite breakdon by nonspecific esterase

Answer 77

SCh- 1-1.5 mg/kg 20mg/ml succinylcholine

Answer 78

Rocuronium .6 mg/kg RSI 1.2 mg/kg Maintence repeat .1 mg/kg Defasciculating – 5mg or 10mg? Onset 1-2 mins … duration about 30 min RSI 70 min 70% liver 30% renal 10mg/ml?

Answer 79

- Induction .1 mg/kg - 10mg vial- reconstituted with 9ml ns. - Maintain .01 mg/kg - Onset- 2-3 mins 3-5 max - Duration- 25-40 for 25% 45-60 mins 95% - 1mg per ml must dilute first

Answer 80

Benylisoquinolines Mivacurium .2 mg/kg and 5-8 mcg/kg/min onset- 1 min duration 10-20 mins

Answer 81

Atracurium .5 mg/kg onset 2-3mins duration - 20-35 mins – 95% recovery 60-70 mins Cisatracurium .15-.2 – mg/kg onset- 2-3 mins peak 4-7 duration- 40-70 – 20-25 begins and 90% 93 mins 2mg per ml

Answer 82

Neostigmine- .04-.08 mg/kg – every 1mg/ml od neostigmine mix with .2mg glycol (1ml) Onset- 15 mins – duration 1-2 hrs- hepatic metabolism excretion urine Edrophonium-(more rapid) .5-1mg with 7-10 mcg/kg of atropine enlon .05-.1mg / kg slowly over a min Sugammadex- is different encapsulates modifiec y-cyclodextrin- 8 sugars water soluble binds rocuronium then vecurnoum. T2- 2mg/kg 2 mins, PTC 1-2 – 4mg/kg 3 mins.., 16 mg – given right after dosing 1.5mins recovery- can have negative effects high dose- brady hypo headache arrest itchy – need contraceptieves 7 days \*\* incompatible with verapamil, ondansetron and ranitidine -anaflaxsis- give epinephrine- 10-20 mcg , Benadryl, dexamethasone, and famotidine Physostigmine- only anticholinesterase that crosses BBB- treats anticholinergic toxicity Cholinergic crisis- atropine 35-70 mcg/kg Pralidoxime 15 mcg/kg every 20 mins Benzos Neostigmine and edrophonium are/have: poorly lipid soluble large volumes of distribution