[1 question/flashcard] Intraop Meds - EVERYTHING
Midazolam dose range
- 02 - 0.04 mg/kg IV
- 4-0.8 mg/kg PO
Midazolam syringe size
3 mL
Midazolam concentration
1 mg/mL
Midazolam preparation
2 mL = 2 mg
Midazolam metab
hepatic CYP 450 - oxidation
Midazolam T1/2
2 hr
Midazolam onset, peak, duration
Onset 30-60 seconds
half-time to peak effect 5 minutes
DOA 30-60 min
Midazolam sticker color
(duller) orange
Fentanyl dose range
1-3 mcg/kg
Fentanyl syringe size
3 or 5 mL
(comes in 2, 5, 10 mL vials) - sim notes
Fentanyl concentration
50 mcg/mL
Fentanyl preparation
(2 mL = 100 mcg)
3 mL = 150 mcg or 5 mL = 250 mcg
Fentanyl onset, peak, duration
onset 3-5 minutes (Even tho Falyar said 1-3 minutes)
peak _____
duration 60 min
Fentanyl sticker color
Carolina Blue
Lidocaine dose range
1-1.5 mg/kg IV
Lidocaine syringe size
5 mL
Lidocaine concentration
1% = 10 mg/mL
2% = 20 mg/mL
Lidocaine preparation
2% → 20 mg/mL → 5 mL = 100 mg
1% → 10 mg/mL → 5 mL = 50 mg
Lidocaine metab
amide local anesthetic: liver metabolism
Lidocaine onset, peak, duration
onset 45-90sec
peak 1-2 min
duration 10-20 min
Lidocaine onset, peak, DOA
onset: 45-90 sec
peak: 1-2 min
DOA: 10-20 minutes
“lido is 1-2, 1-2 min 10-20 min”
Lidocaine sticker color
gray
Propofol dose range
1.5-2.5 mg/kg IV
Propofol syringe size
20 mL
Propofol concentration
10 mg/mL
Propofol preparation
20 mL = 200 mg
Propofol onset, peak, duration
onset 30-60 sec
peak _____
duration 5-15 min
Propofol T1/2
30-90 min
(Falyar said 11.5 hrs LOLOL)
Propofol metabolism
hepatic glucuronidation
Propofol sticker color
yellow
Etomidate dose range
0.2 - 0.4 mg/kg IV
Etomidate syringe size
10 mL
Etomidate concentration
2 mg/mL
Etomidate preparation
10 mL = 20 mg
Etomidate onset, peak, duration
onset 30-60 seconds
(1 arm-to-brain circulation)
peak 1 minute
duration 5-15 min (OTHER CHART SAID 3-10 min)
AN ATOM BOMB TAKES 1 minute to go off, you know withni 5- 15 minutes if you want to end a date
Etomidate T1/2
2-5 hrs
Etomidate metabolism
hydrolysis by plasma esterases
and hepatic metabolism
Ketamine dose range (IV)
1-2.5 mg/kg
Ketamine syringe size
Ketamine concentration
“5-100 mg/mL”
5 mg/mL
10 mg/mL
50 mg/mL
100 mg/mL
Ketamine preparation
often diluted to 10 mg/mL
50 mg/mL → 1 mL + 4 mL NS = 10 mg/mL
100 mg/mL → 1 mL + 9 mL = 10 mg/mL
Succinylcholine is dosed based on…
Ketamine onset, peak, duration
onset 30-60 seconds
peak _____
duration 5-10 minutes
“keta-mine, 5-TEEN (southern accent)”
Ketamine T1/2
2-3 hrs
(Nagelhout)
Ketamine metabolism
*CYP 450 - demethylation primary metab → norketamine
then hydroxylation → other metabolites form a glucuronidation derivative (H2O-soluble) → renal excretion
Succinylcholine dose range
(Trade: Anectine)
1 mg/mL
Succinylcholine syringe size
(Trade: Anectine)
10 mL
Succinylcholine concentration
(Trade: Anectine)
20 mg/mL
Succinylcholine preparation
10 mL = 200 mg
Succinylcholine onset, peak, duration
onset 30-60 seconds
peak 1 minute
duration 3-5 minutes (sim drug guide)
5-15 minutes (drug chart)
- call it even and say 5-10 min - Nagelhout’s #*
- (full recovery in 12-15 minutes - Nag)*
Succinylcholine T1/2
2-4 minutes
Succinylcholine metabolism
(quick) hydrolyzed by plasma esterases
remember PChE deficiency
Succinylcholine sticker color
neon orange
neon orange = muscle relaxers
Succinylcholine (Anectine) considerations:
who would you give to
who would you avoid it in
Give:
- RSI: 1.5 mg/kg
Avoid:
- peds < 5 yrs (risk for DMD)
- hyperK+ patients
- can give in renal pts if their K+ is normal (nagelhout)
- lower motor neuron disease (upregulation of nAChRs) = give less or avoid in all of them except for MG
- MG pts are resistant to succ bc they have less nAChRs (antibodies blocking the reeceptor)
- lower PChE activity: advanced liver dz, age, malnutrition, pregnancy, burns, PO laxatives, MAOIs, echothiopate, cytotoxic drugs, anticholinesterase drugs
don’t have to avoid, but need much lower doses of nondepolarizers for all of them
Succinylcholine (Anectine) considerations:
side effects
- neuro: ↑ ICP/IOP
- CV: tachycardia, but could cause sudden bradycardia in peds (or repeat doses in adults), falyar said bradycardia/junctional/sinus arrest
- labs: intubating dose increases K+ by 0.5-1 mEQ/dL
- GI/GU: ↑ gastric pressure/lower esophageal pressures, myoglobinuria
- MSK: myalgia, masseter spasm - could be d/t MH or inadequate dosing
- decreased synth of PChE in hepatitis/cirrhosis
- dibucaine number
- normal = 80% of PChE was inhibited by dibucaine
- 40-60 = prolongs block 1.5-2x longer
- <30 = prolongs block for 4-8 hrs!
Glycopyrrolate Dose
5-10 mcg/kg
= .005 - 0.01 mg/kg
so just stick to 0.01 mg/kg
(other chart says 0.01-0.02 mg/kg)
“glyco-pyro, starts with 5 yo”
glycopyrrolate syringe
3 or 5 mL
Glycopyrrolate onset, peak, duration
onset < 1 minute
peak 5 minute
duration 2-4 hrs
glyco and neostigmine are slower onset, but sustained effect
Glycopyrrolate T1/2
Nagelhout: less than 10% of drug is in the serum after 5 minutes
85% of IV dose is excreted in urine within 48 hrs
Glycopyrrolate metabolism
Nagelhout: excreted in the feces/urine, primarily as unchanged drug
(makes sense bc highly charged)
“small amts are metabolized into inactive metabolites”
Glycopyrrolate sticker color
(Trade: Robinul)
lime green
“Lime green, Atropine → lime green = antimuscarinics”
glycopyrrolate concentration
0.2 mg/mL
Atropine Dose
7-10 mcg/kg (Falyar)
= 0.007-0.01 mg/kg
(other chart says 0.01-0.03 mg/kg)
“Atro-pine, 7-to-ten”
Atropine syringe size
3 mL
Atropine concentration
- 04% = 0.4 mg/mL
- 01% = 0.1 mg/mL
or 1 mg/mL
Atropine Preparation
1 mL = 0.4 mg
(2 vials) 2 mL = 0.8 mg
1mL = 1 mL
Atropine onset, peak, duration
onset 45-60 seconds
peak 2 minutes
duration 30 minutes
(somewhere else said DOA is 1-4 hrs)
(Remember that glyco-neo are slower than atropine/edrophonium - but they last longer)
Atropine T1/2
2-3 hrs
Atropine metabolism
both liver and kidney:
metabolism by liver, and 30-50% excreted unchanged in the urine
Atropine sticker color
lime green
“Lime green, Atropine → lime green = antimuscarinics”
Neostigmine Dose
0.05 mg/kg
(range 0.04-0.08 mcg/kg)
Max dose 5 mg
Neostigmine concentration
0.5 - 1 mg/mL
Ex: 70 kg person x 0.05 mg/kg = 3.5 mg
3.5 mg = 3.5 mL or 7 mL
Neostigmine preparation
5 mL = 5 mg
(70 kg person at 0.05 mg/kg = 3.5 mg)
Neostigmine syringe
5 mL
(if using 1 mg/mL concentration)
(10 mL if using 0.5 mg/mL concentration)
Neostigmine onset/peak/duration
Onset 5 minutes
Peak 7 minutes
DOA 1-2 hrs
(as opposed to Edrophonium DOA only up to 1 hr)
Neostigmine sticker color
white, with red candy stripe border
Neostigmine T1/2
Edrophonium dose range
0.5-1 mg/kg
Rocuronium dose range
(Trade: Zemuron)
- 6 mg/kg - standard induction
- 2 mg/kg - RSI
Rocuronium syringe size
5 mL
Rocuronium concentration
10 mg/mL
Rocuronium/Zemuron sticker color
neon orange
neon orange = muscle relaxers
Rocuronium preparation
(Trade: Zemuron)
5 mL = 50 mg
(might need 2 vials and syringes)
Rocuronium Onset, Peak, Duration
Onset: 45-90 seconds minute
Peak: 1-3 minutes
Duration: 30-60 min
Rocuronium metabolism
hepatic and renal
33% renal (nagelhout)
Rocuronium (Zemuron) T1/2
1-2 hrs
Rocuronium (Zemuron) anesthetic considerations:
when would you use it
when would you avoid it
Use: RSI, need muscle paralysis <30-60 min
Avoid: renal pts
Vecuronium dose
(Trade: Norcuron)
0.1 mg/kg
Vecuronium syringe size
(Trade: Norcuron)
10 mL
Vecuronium concentration
(Trade: Norcuron)
1 mg/mL
Vecuronium sticker color
neon orange
neon orange = muscle relaxers
Vecuronium preparation
(Trade: Norcuron)
10 mg powder into 10 mL NS
10 mL = 10 mg
Vecuronium (Norcuron) T1/2
51-90 min (Nagelhout)
Vecuronium (Norcuron) metabolism
liver and kidneys
Vecuronium onset, peak, DOA
onset: 3 minutes
peak: 3-5 minutes
DOA: 25-30 minutes
“3-3-30”
Vecuronium (Norcuron) anesthetic considerations
liver > kidney metabolism … but still avoid in renal pts
slower onset (3-5 min)
Cisatricurium dose range
(Trade: Nimbex)
0.1-0.2 mg/kg
“Sis, you have 0.1 seconds to get out of my face” idk it works
CIsatricurium syringe size
(Trade: Nimbex)
5 mL (may need 2 vials)
CIsatricurium concentration
(Trade: Nimbex)
2 mg/mL
Cisatricurium onset, peak, duration
onset: 2 minutes
peak: 2 minutes
DOA: quick! 20-35 min
(same DOA as VEC)
(another source says 6-16 min)
CIsatricurium preparation
(Trade: Nimbex)
5 mL = 10 mg
(might need 2 vials)
example calculation 70 kg person = 7 mg, or 14 mg
Cisatricurium metabolism
Hoffman Elimination in plasma and tissues
pH and temperature dependent
Hoffman accounts for 77% of elim of cis, and the other 23% is from plasma esterases
Cisatracurium considerations
Laudanosine liberation (although 1/5 as much as atracurium). This means that the pt is at risk for convulsions, bc it crosses the BBB!
Laudanosine requires liver for metabolism, excreted in the bile and urine (so biliary obstructed pts will have an issue with this)
This is more a consideration for atracurium tbh.
Cisatracurium T1/2
1 hr
Phenylephrine sticker color
(Trade: Neosynephrine)
purple
pressors = purple
dose range
syringe size
concentration
preparation
onset, peak, duration
T1/2
metabolism
signs of MH
increase in EtCO2
muscle rigidity (↑ peak pressures)
metabolic acidosis
high temperature (late sign)
