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Anesthesiology > 7/8: Preanesthetic Meds > Flashcards

7/8: Preanesthetic Meds Flashcards

1
Q

What are advantages of using anticholinergics as part of pre-anesthetic meds?

A

Prevention of salivation, airway secretions, bradycardia

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2
Q

What are advantages of using maropitant as a pre-anesthetic med?

A

Prevention of nausea and vomiting;

It also provides adjuct analgesia (NK-1 antagonist) and decreases inhalant requirements

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3
Q

What are 5 general advantages to using pre-anesthetic meds?

A
  1. Chemical restraint
  2. Decreased stress/anxiety –> decreased catecholamines –> decreased risk of arrhythmias
  3. Decreased induction and inhalant anesthetic doses
  4. Pre-emptive analgesia
  5. Smooth recovery
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4
Q

What is pre-emptive analgesia?

A

Treatment initiated before surgery in order to prevent the establishment of central sensitization evoked by incisional and inflammatory injuries occurring during surgery and in the early post-op period.

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5
Q

What are 4 disadvantages to using pre-anesthetic meds?

A
  1. Bradycardia
  2. Hypotension
  3. Excitement/dysphoria
  4. Nausea/vomiting
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6
Q

What pre-anesthetic med types cause bradycardia?

A

Alpha-2 agonsists, opioids

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7
Q

What pre-anesthetic med types cause hypotension?

A

Acepromazine, alpha-2 agonists

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8
Q

What pre-anesthetic med types cause excitement/dysphoria?

A

Opioids, benzos

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9
Q

What pre-anesthetic med types cause nausea/vomiting?

A

Mu-agonist opioids, dexmedetomidine

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10
Q

What are 6 factors to consider when selecting a pre-anesthetic medication?

A
  1. Species
  2. Health status of patient
  3. Pain (existing and expected)
  4. Temperament
  5. Duration of procedure
  6. Anticipated side effects of drugs administered
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11
Q

What 4 drug types can be used as analgesics?

A
  1. Opioids
  2. Dissociatives
  3. NSAIDs
  4. Alpha-2 agonists, maropitant
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12
Q

What 2 drugs can be used as anticholinergics?

A
  1. Atropine
  2. Glycopyrrolate
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13
Q

What 3 drug types can be used as tranquilizers/sedatives (neuroleptics)?

A
  1. Phenothiazines
  2. Alpha-2 agonists
  3. Benzos
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14
Q

What 3 categories of drugs are used for premeds?

A

Opioids, sedatives/tranquilizers, anticholinergics

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15
Q

What 5 opioid drugs are pure mu agonists?

A
  1. Hydromorphone
  2. Fentanyl
  3. Morphine
  4. Methadone
  5. Oxymorphone
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16
Q

What opioid drug is a mixed kappa agonist/mu antagonist?

A

butorphanol

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17
Q

What opioid drug is a partial mu agonist?

A

Buprenorphine

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18
Q

What opioid drugs are full mu antagonists?

A

Naloxone, naltrexone

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19
Q

What are the 3 opioid receptors?

A

mu, kappa, delta

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20
Q

Where are opioid receptors located?

A

In peripheral and central nervous systems

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21
Q

What is the mechanism of action for opioids?

A

Opioid receptors are coupled with inhibitory G-proteins (GPCRs) which activate 2nd messenget systems in cells

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22
Q

What are the 2nd messenger systems that are activated by G-proteins?

A
  1. Closing of Ca channels
  2. Efflux of K –> hyperpolarization
  3. Decreased cAMP production
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23
Q

What are 4 overall results that opioids have on cells?

A
  1. Hyperpolarization
  2. Decreased neuronal excitability
  3. Decreased neurotransmitter release
  4. Decreased transmission of nerve impulses
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24
Q

Naxolone is such a weak mu _____ that we consider it an _____.

A

agonist, antagonist

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25
Q

Effects of mu/kappa agonists are _____ dependent, and there is no _____ effect.

A

dose, ceiling

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26
Q

What are some clinical side effects cause by mu agonists?

A
  1. Analgesia
  2. Inhalant sparing
  3. Mild to profound sedation
  4. Bradycardia
  5. Respiratory depression
  6. GI: nausea, vomiting, decreased motility
  7. Urinary retention
  8. Hyperthermia in cats
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27
Q

What does it mean if a drug has a ceiling effect?

A

Increased dose does not = increased analgesia

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28
Q

What 2 opioid types have a ceiling effect?

A

Partial mu agonists (Buprenorphine)

K agonist/mu antagonist (Butorphanol)

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29
Q

What can Butorphanol be used with?

A

Dexmedetomidine

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30
Q

What type of analgesia do opioids provide?

A

Somatic and visceral

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31
Q

When do opioids provide mild sedation?

A

When used alone

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32
Q

What mild CV effects do opioids have?

A
  1. Decreased HR due to increased vagal tone –> anticholinergic
  2. Little/no effect on vasculature (histamine release)
  3. Little/no effect on cardiac contractility
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33
Q

Opioids _____ the MAC of inhalant.

A

decrease

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34
Q

When should you use full mu agonists?

A

With moderate to severe pain

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35
Q

What is the duration of action of hydro/oxymorphone?

A

2-4 hours

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36
Q

What is the duration of action of morphine/methadone?

A

4-6 hours

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37
Q

Methadone is an NMDA _____.

A

antagonist

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38
Q

What effects can morphine have on vasculature?

A

Histamine release

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39
Q

A side effect of full mu agonists is ______ to ______ analgesia.

A

moderate, severe

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40
Q

What is a CV side effect that mu agonists cause?

A

bradycardia

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41
Q

What GI side effects do mu agonists cause?

A

Nausea, vomiting, defecation

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42
Q

What do mu agonists cause in cats specifically? (side effect)

A

hyperthermia

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43
Q

What can you give together with hydromorphone to mitigate the side effects?

A

fentanyl

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44
Q

What type of drug is fentanyl?

A

pure mu agonist

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45
Q

What is the duration of fentanyl?

A

15-30 min

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46
Q

What is done to mitigate the short duration of fentanyl?

A

Given IV as a CRI

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47
Q

What is a CV side effect of fentanyl?

A

Bradycardia (> other mu agonists)

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48
Q

What are GI side effects of fentanyl?

A

No vomiting; may cause nausea

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49
Q

Fentanyl can cause respiratory _____.

A

depression

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50
Q

What should be monitored intra-op when fentanyl is on board?

A

EtCO2, IPPV

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51
Q

What should be monitored post-op when fentanyl is on board?

A

SpO2

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52
Q

What are 3 ways that we use fentanyl?

A
  1. Induction agent in critically ill SA patients
  2. Intra-op and post-op CRI
  3. Patch (post-op)
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53
Q

Buprenorphine produces _____ sedation, and _____ to _____ analgesia.

A

mild, mild, moderate

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54
Q

What is the onset of buprenorphine?

A

30-45 min (slow)

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55
Q

What is the duration of buprenorphine in dogs and cats?

A

Dogs = 4-10 hours

Cats = 6-12 hours

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56
Q

Buprenorphine has a strong _____ for the mu receptor.

A

affinity

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57
Q

When should you not use buprenorphine as a pre-med?

A

If the procedure is painful

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58
Q

What is a disadvantage of buprenorphine?

A

It is difficult to reverse

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59
Q

What is the SA dose of buprenorphine?

A

0.01 - 0.04 mg/kg

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60
Q

How does buprenorphine compare to mu agonists?

A

It has LESS:

  1. Respiratory depression
  2. Panting
  3. Bradycardia
  4. Analgesia, MAC sparing
  5. No nausea, vomiting
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61
Q

What is the new, long acting formulation of buprenorphine approved for cats?

A

Simbadol - 0.24 mg/kg SQ SID

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62
Q

Because butorphanol is a mu antagonist, it is a partial _____ _____.

A

reversal agent

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63
Q

Butorphanol provides _____ sedation and analgesia.

A

mild

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64
Q

How long does sedation with butorphanol last? Analgesia?

A

Sedation = 1-2 hours

Analgesia = ~90 min

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65
Q

How does butorphanol compare to mu agonists?

A

It has LESS:

  1. Respiratory depression
  2. Panting (seen at higher doses)
  3. Bradycardia
  4. Analgesia, MAC sparing
  5. No nausea/vomiting
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66
Q

What does butorphanol prevent that dexmedetomidine causes?

A

nausea/vomiting

67
Q

What type of procedure should butorphanol be used for?

A

Sedation for non-painful procedures (i.e. x-rays)

68
Q

How is butorphanol used in dogs and cats?

A

Alone (dogs) or with sedative/tranquilizer

69
Q

What is the dose for butorphanol?

A

0.2 - 0.4 mg/kg

70
Q

How should butorphanol be used in horses?

A

With alpha-2 agonist for pre-med/intra-op

71
Q

How should butorphanol be used in large ruminants? Small ruminants?

A

Large = during/after induction (vocalization)

Small = as premed + benzodiazepine

72
Q

What are the 4 sedatives/tranquilizers used?

A
  1. Acepromazine
  2. Alpha-2 agonists
  3. Benzodiazepines
  4. Dissociatives - not sedatives but used for chemical restraint
73
Q

What is an alpha-2 agonist used in SA?

A

Dexmedetomidine

74
Q

What are 3 alpha-2 agonists used in LA (primarily horses)?

A
  1. Xylazine
  2. Detomidine
  3. Romifidine
75
Q

What are 2 common benzodiazepines used?

A

Midazolam and Diazepam

76
Q

What are 2 dissociatives used for chemical restraint?

A
  1. Ketamine
  2. Tiletamine (in Telazol)
77
Q

What type of drug is acepromazine?

A

Phenothiazine

78
Q

What does acepromazine do cellularly?

A

Blocks dopamine, 5-HT, and alpha-1 adrenergic receptors

79
Q

What anatomical locations does acepromazine act on?

A

Basal ganglia, hypothalamus, limbic system, brain stem, reticular activating system (RAS)

80
Q

Why is acepromazine an effective tranquilizer?

A

It blocks D and 5-HT Rs –> depression of brain stem and RAS connections to cerebral cortex

81
Q

How does acepromazine affect the vessels?

A

Causes vasodilation through an alpha-1 adrenergic blockade

82
Q

What CV effects does acepromazine have?

A
  1. Decreased symp tone (sinus bradycardia, 2nd deg AV block)
  2. “Anti-arrhythmic” effect - cardiprotectant
83
Q

What respiratory effect does acepromazine have?

A

resp depression

84
Q

Ace _____ nausea/vomiting through ___ receptors in the chemoreceptor trigger zone.

A

decreases, D

85
Q

What effect does ace have on PCV?

A

Decreased due to splenic sequestration

86
Q

What effect does ace have on platelets?

A

Altered plt function

87
Q

What effect does ace have on body temp?

A

Hypothermia (peripheral vasodilation or effects on hypothalamus, redist of blood from core to periphery)

88
Q

Ace does not have _____ effects BUT has synergistic effects with _____.

A

analgesic, opioids

89
Q

Ace _____ induction dose and MAC of inhalant.

90
Q

Ace produces _____ to _____ sedation.

A

mild, moderate

91
Q

What is the onset of action of ace?

A

~20-30 min

92
Q

What is the duration of ace?

93
Q

T/F: Ace has a reversal agent

94
Q

Where is ace metabolized and excreted?

A

Metab in the liver, excreted by kidney

95
Q

What can happen if ace is accidentally injected into the carotid in horses?

A

Seizures and death

96
Q

Why should ace not be used for allergy testing?

A

Blocks histamine

97
Q

What are 3 contraindications for ace use?

A
  1. Moderate/severe liver dysfunction
  2. Hypovolemia, shock, critically ill patients
  3. Paraphimosis in stallions –> relaxation of penis retractor muscle via alpha-1 blockade
98
Q

What dogs cannot have ace?

A

Those with a mutation in the ABCB1/MDR1/P-gp gene (i.e collies)

99
Q

How can ace be administered?

A

PO, SQ, IM, IV

100
Q

What is the dosage for ace?

A

0.005 - 0.02 mg/kg IM or IV

101
Q

What is the alpha-2 to alpha-1 receptor ratio?

102
Q

What are the 3 isoreceptors of alpha-2 drugs?

A

Alpha-2A, alpha-2B, alpha-2C

103
Q

What type of receptor are alpha-2 receptors?

104
Q

Where is the alpha-2A receptor and what is its effect?

A

In locus ceruleus (brain) –> inhibition –> sedation, anxiolysis, sympatholytic properties

105
Q

Where is the alpha-2B receptor and what is its effect?

A

In vasculature –> excitatory –> vasoconstriction

106
Q

Where are therer both alpha-2B and 2C receptors and what is their effects?

A

Dorsal horn of spinal cord –> inhibit nociception

107
Q

What are the biphasic CV effects of alpha-2 agonists?

A
  1. Initial hypertension (10-30 min) response due to peripheral alpha-2B stim with vasoconstriction
  2. Central alpha-2A stim –> decreased NE –> hypotension due to bradycardia and peripheral vasodilation
108
Q

In relation to alpha-2 agonists:

Initially, bradycardia is a _____ mediated response due to increased BP, while decreased _____ slows HR in latter phase.

A

baroreceptor, sympathetic outflow

109
Q

What is the treatment for alpha-2 agonist induced bradycardia that has a normal to high BP and why?

A

No treatment necessary because anti-cholinergics will increase BP too much and can cause retinal hemorrhage and detachment.

110
Q

What is the treatment for alpha-2 agonist induced bradycardia that has a low BP and why?

A

Treatment with anti-cholinergic indicated ~ 1 hour after administration due to central alpha-2A sympatholytic effect

111
Q

What are 3 uses for dexmedetomidine?

A
  1. Premed (dogs and cats)
  2. Intra-op CRI (dogs, cats, horses)
  3. Sedation for recovery (dogs and cats)
112
Q

What is the dosage for dexmedetomidine as a premed?

A

5.0 - 10 mcg/kg

(Lower end in dogs, higher end in cats)

113
Q

What is the analgesic/sedative effect of dexmedetomidine?

A

potent and dose-dependent

114
Q

What is the onset of dexmedetomidine?

A

Rapid (~5 min)

115
Q

What is the duration of action of dexmedetomidine?

A

Short (~30-60 min, dep on dose)

116
Q

What is the dosage for dexmedetomidine as an intra-op CRI?

A

1.0 - 2/0 mcg/kg/hr

117
Q

What is the dosage for dexmedetomidine when used in sedation for recovery?

A

0.5 - 1.0 mcg/kg IV

118
Q

What CV effects does dexmedetomidine have?

A

40% decrease in CO, reflex bradycardia due to vasoconstriction

(Can decrease chance of heart attack post-op in humans)

119
Q

Can dexmedetomidine be reversed?

A

Yes - Atipamazole (Antisedan®)

120
Q

What type of patient should dexmedetomidine be reserved for?

A

Healthy or very painful, fearful, aggressive patients

121
Q

What can be added to dexmedetomidine if the patient is unhandleable after administration?

A

Ketamine 1.0 - 2.0 mg/kg

122
Q

What alpha-2 agonists can be used in horses? What are the reversals?

A

Xylazine, Detomidine, Romifidine;

Reversals = yohimbine, tolazoline

123
Q

What is the cellular effect/method of action of Benzodiazepines?

A

Enhance effect of ntm GABA at the GABAA receptor –> increase Cl into cell –> hyperpolarization

124
Q

What can benzodiazepines be used for, generally?

A

Sedation, hypnosis, anxiolysis, amnesia, anticonvulsant, muscle relaxant

125
Q

What are 2 benzodiazepines that are commonly used?

A

Diazepam and Midazolam

126
Q

Diazepam and midazolam typically are NOT good _____ in young, healthy dogs and cats. What can they be used for?

A

sedatives;

Diazepam = tx of seizures

Midazolam = premed

127
Q

What do Diazepam and Midazolam do that we do not want to happen?

A

Cause paradoxical excitement, hyperresponsiveness

128
Q

What animals experience more profound sedation with BDZ?

A

Pediatric (<3 mos), geriatric, critical, small ruminants, neonatal foals

129
Q

What is the severity of CV effects of BDZ?

130
Q

What is the respiratory effect of BDZ?

A

Enhances resp depression of other drugs

131
Q

Where are BDZ metabolized?

A

Liver - both have active metabolites

132
Q

What is the 1/2 life of diazepam in dogs? Cats? Horses?

A

Dogs = 2-4 hours

Cats = 5.5 hours

Horses = 7-22 hours

133
Q

What is the 1/2 life of midazolam in dogs? horses?

A

Dogs = ~70 min

Horses = ~3-6 hours

134
Q

What do BDZ NOT provide?

135
Q

What does diazepam contain that can cause issues?

A

Propylene glycol;

Pain on injection, not well absorbed, toxic at high doses

136
Q

What is the relative cost of midazolam and diazepam?

A

Relatively similar

137
Q

What do we use midazolam with in dogs and cats?

A

With an opioid for premed in very young, geriatric, or sick patients

138
Q

What is the dosage for midazolam in dogs and cats?

A

0.1 - 0.2 mg/kg IM or IV

139
Q

What induction agent dose can be reduced if midazolam is used as an adjunct with it in dogs and cats?

140
Q

What drug is midazolam used as a co-induction agent with in adult horses?

141
Q

What drug is midazolam used as a co-induction agent with in neonate horses?

A

Butorphanol

142
Q

What drug is midazolam used as a co-induction agent with in small ruminants?

A

Ketamine or Propofol

143
Q

What is the method of action of anti-cholinergics?

A

Antagonize ACh at muscarinic Rs at post-ganglionic sites in parasympathetic nervous system (increases sympathetic tone)

144
Q

What do anti-cholinergics do to vagal effects and salivary secretions?

A

Decreases them

145
Q

What are anti-cholinergics primarily used for?

A

To counter vagal effects of anesthetic drugs

146
Q

What are the 2 most common anti-cholinergics?

A

Atropine and Glycopyrrolate

147
Q

What effect do anti-cholinergics have on the heart rate?

A

Increases it

148
Q

What effect do anti-cholinergics have on salivation?

A

Decreases it

149
Q

What effect do anti-cholinergics have on mucociliary transport/clearance?

A

Decreases it

150
Q

What effect do anti-cholinergics have on the pupils?

A

Dilates them (atropine)

151
Q

What effect do anti-cholinergics have on GI motility in LA?

A

Decreases it; relaxation of gastro-esophageal sphincter

152
Q

What effect do anti-cholinergics have on blood flow?

A

Decreases it –> myocardial ischemia/hypoxemia

153
Q

What heart conditions can anti-cholinergics be used to treat?

A

Sinus bradycardia, 1st and 2nd deg AV block, sinus arrest, CPCR

154
Q

What is the onset of action of atropine?

A

<5 min IM

<1 min IV

155
Q

What is the duration of action of atropine?

A

~30 min IV

156
Q

What is atropine capable of crossing?

A

BBB/placenta;

Reason some people don’t like to use it in C-sections

157
Q

What is atropine more likely to cause than glycopyrrolate?

A

Sinus tachycardia

158
Q

T/F: Glycopyrrolate crosses BBB/placenta

159
Q

What is the onset of action of glycopyrrolate?

160
Q

What is the duration of action of glycopyrrolate?

161
Q

Why should glycopyrrolate be avoided in LA?

162
Q

What are 2 approaches for use of anti-cholinergics in SA?

A
  1. Pre-treatment (expense, risk of tachycardia)
  2. Treat if needed (monitor HR, rhythm, BP)
163
Q

What 4 cautions should be taken when considering an anti-cholinergic?

A
  1. LA
  2. Geriatric patients or those with heart disease
  3. Patients with low HR/high BP (dexmedetomidine)
  4. Ineffective in patients with moderate/severe hypothermia
164
Q

What are 3 considerations for an individualized anesthesia and analgesia plan that includes a preanesthetic?

A
  1. Opioid Analgesic - butorphanol, buprenorphine, full mu agonist (or fentanyl IV)
    1. Based on spp, pain, inhalant sparing needs, cost, availability
  2. Tranq/Sedative - acepromazine, alpha-2 agonist, BDZ, GG
    1. Based on signalment, temperament, physical status, co-morbidities
  3. +/- Anti-cholinergic

Anesthesiology (12 decks)

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