ACE Review - Pharm Flashcards
Moa clopidogrel and ticlopidine
Inhibit adenosine diphosphate receptors.
Moa aspirin
Stops cox1 from changing arach to thromboxane.
Moa tirofibran and abciximab.
Irrev binder of g3p2 receptors.
Moa of Gabapentin.
L type calcium channels on the alpha 2 delta subunit.
Does Gabapentin work on GABA receptors?
no
common triggers for malig hypertherm
volatiles and succ
what gene mutation is prone to malignant hyperthem
ryr1 gene in chrom 19
malignant hyperthermia moa
irregular release of intracell calcium…intracell contraction, atp, depletion, acidosis, cell death
dose if dantrolene
2.5mg/kg
does nitrous oxide cause MH
no
does intravenous anesthestics cause MH
no
how to treat hyperkalemia in MH
bicarb, glucose/insulin, calcium chloride
is cacl or ca gluconate adding to hypercalemic state of MH
no, the hypercalcemic state occurs intracell, not extracell, main goal is to treat arrythmia
what is not a treatment drug for MH assoc arrythmia
calcium channel blockers because they work against dantrolene
goal urine output in MH
2cc/kg/min
goal temp of MH
36-38, not higher or lower
is 2.5mg/kg dantrolene enough
no sometimes titrated up to 10mg/kg
what kind of mm relaxant is roc
monoquaternary aminosteriod
what is likely to decrease when given atropine
decrease in bronchopulmonary tone
what happens to body temp when given atropine
it increases body temp because there is a decrease in sweat gland secretions
what happens to the urine when given atropine
decrease urine output because it prevents urethral relaxation
what happens to the gi tract when given atropine
constipation, decrease acid secretion, decrease LES tone
what happens to the eye with atropine
mydriasis and increased intraocular pressure
which muscarinic recepter does atropine work on
m3
if there is a decrease in cardiac output, the rate of change of FA/FI is less likely affected by what
the less soluable gas is minimally affected by a decrease in cardiac output
what is the value used to measure the solubility of a gas
bloodgas partition coefficient
what gases are more affected by a decrease or change in cardiac output
soluble gases
what are the solubility of the gases
iso 1.46 sevo 0.65 dess 0.46, nitro 0.42
what are the effects of IV anesthetics on cerebral blood flow
most decrease cbf…like propofol.
what is the one IV anesthetic that actually increases cbf
ketamine
what do gases do to your cerebral blood flow
increase
what kind of cancer does doxyrubicin help treat
leukemia and lymphoma; wilms tumor, osteogenic sarcoma, breast carcinoma
what is the most common pathology seen by using doxyrubicin
cardiomyopathy
what is the screening test of choice for doxyrubicin
echocardiogram
why cant you use an ekg for doxyrubicin
ekgs most likely will show non-specific changes…like sinus tach, st segment changes, low voltage qrs
if a pt is getting 400mg/m^2, what is the chance of having cardiomyopathy
0.14%
if a pt is getting 550mg/m^2 doxyrubicin, what is the chance of having cardiomyopathy
7%
what does the increase in dose to increase of chances of cardiomyopathy with doxyrubicin mean?
cardiomyopathy is dose dependant
when can late onset of doxyrubicin induced cardiomyopathy occur
4 years after completion of doxy treatment
how common is doxy cardiomyopathy of late onset
it happens in 65% of patients
how specific and sensitive is echo in detecting doxy assoc cardiomyopathy
81%specific, 64% sensitive
what is the echo followup timeline after completing doxy treatment
at 3 6 and 12 months after completion and q 2 years after that
should we use cxray to screen doxy assoc cardiomyopathy
no…it usually detects late signs…and pts benefit from early intervention rather than late intervention
what is propofol infusion syndrome
myocardial failure, dysrythmia pluse 2 of 3 other criteria
what is the other possible criteria of propofol infusion syndrom
metabolic acidosis, rhyabdomyolysis, hyperkalemia
what kind of EKG finding do you find in propofol infusion syndrome
brugada like ekg signs…st elevated in v1-v3 without actually having ischemia
why do you mainly see propofol infusion sydrom in critically ill pt
because they have a very high energy requirement
how does propofol infusion syndrome hurt critically ill pt
at doses 130mcg/kg/min or higher, it can inhibit mitochondrial energy production and prevent oxidation of fatty acids
what is precentage of death In peds poplulation with propofol infusion syndrome
71%
what is the percentage of death in adults with propofol infusion syndrome
31%
what is the difference of an infiltrated IV versus an extravasiated IV
extravasiated iv has vesicants
what are vesicants
those that causes blisters
what are examples of vesicants
pressors, drugs that has Ca and K, some abx, mannitol and chemo agents
how does mannitol cause blisters
because it is hyperosmolar…driving fluid into the extravasation
what is the treatment for mannitol blisters
pressors and pH neutralizing solutions
when is surgery needed for mannitol extravasation
when compartment syndrome is present
what is the cross reactivity of pcn to 3/4th gen cephalosporins
5-12%
what are the other drugs can you use if pcn allergy
vanco and clindamycin
is there data to support premedication to prevent anaphylactic reaction to meds?
no..
what factors affect placental tranfer in drugs
lipid soluble, unionized, small molec weight, low protien binding
what affects a drugs ionization
the drugs pka and the environment ph
why does neuromuscular blocking drugs not cross placenta
because it is highly ionized
why does isoflurane cross over placenta so fast
because it is highly lipid soluble and low molec weight
why does sufent cross the placenta so fast
because it is highly lipid soluble
what narcotic has a black box warning
methadone
what kind of black box risk is there for methadone
cardiac arrythmias
what are 2 things dangerous about methadone
it prolongs QTc, it has a huge variability in patients bioavailability
what other drug do you have to do serial EKGS for like methadone users
droperidol
where does methadone get broken down
liver
what p450 enzymes does methadone get broken down into
3A4, 2D6
what meds might increase methadone because they inhibit 3A4 P450?
grape fruit and fluoroquinone antibiotics
what meds might increase methadone because they inhibit p450 2d6
SSRI fluoxetine, paroxitine
why does methadone vary so much in patients.
at certain doses, methadone actually induces its own metabolism, bioavailability varies among pts as well
why does methadone not work so well in cancer patients.
methadone is highly protien bound. In cancer patients, they have a reactive protien Alpha1A that is increased and binds the drug…decreasing its availabilty
do inhaled steriods for asthma cause adrenal corticoid suppression
no
what electrolyte abnormality do you see in pt using short actiing beta 2 agonist
hypOkalemia and hypOmag
what caution do you need to have when using mucolytics with asthma patients
they can actually cause bronchospasm
what is the onset and duration of short acting beta 2 agonist drugs for asthma
onset 5 mins duration 4-5 hours
what is an example of a short acting beta 2 agonist asthma drug
albuterol
what is the onset and duration of long acting beta 2 agonist for asthma drugs
no immediate effect…duration 12 hours s/p inhaler use
what are some examples of long acting beta2 agonist asthma drugs
salmaterol
what is bad about long beta 2 agonist
black box warning showing an association of increased mortality 1/1125 pts studied
along with short acting betal 2 agonist, what other drugs are used to treat asthma
inhaled corticosteriods
does using short term beta 2 agonist along with long acting beta 2 agonist
no they do not affect eachother
if the beta2/steriods inhaler fails to work, what is the next step of meds
parentral steriods
when do you see the effect of parentral steriods
4-6 hours onset
when pt becomes intolerant to beta 2 steriods…what other drugs can be used
anticholinergic…like ipratroprium
when is ipratroprium most effective
it is more effective in COPD pts
what is albuterol plust ipratropium
that is combivent
what is a dangerous side effect of combivent
flu like symptoms that occur in 1/20 pts
when is a pt on oral/parentral steriods for asthma be considered andreal suppressed
at least 2 weeks usage w/in the last 6 months
what happen to electrolytes with chronic lasix
hypoKalemia hypoMag
what is increased in chronic lasix usage
bicarb
how is calcium affected with chronic lasix usage
it is not affected
what happens to bicarb in chronic lasix usage
it is increased 2ndry to contraction alkalosis and due to H and Cl secretion for Na preservation
is poor o2 sat a good indicator of cyanide toxicity
no, actually your pulse ox would actually read a normal sat
is measuring serum cyanid levels a good way to test for cyanide toxicity
toxicity is dependant on dose and rate of release of cyanide…cyanide levels are difficult to attain and thus not a good way to check for toxicity
is a brown color of blood a good way to check for cyanide toxicity
actually the blood will be bright red…think of other pathology like meth-hemoglobinemia…which will be brown
what drug has cyanide as a metabolite
nitroprusside
what happens to the mix venous blood of cyanide poisoning
it is elevated
why dose cyanide cause a mix venous to have a higher amount of o2
because it displaces o2 from the hemoglobin
if cyanide displaces o2 from hemoglobin, what else is elevated other than mix venous o2
partial pressure of o2 in blood
what is the best and easiest way to check for toxicity by cyanide
check blood ph it will show metabolic acidosis
what is a drug that can help with cyanide toxicity
thiosulfate, vitamin b12
how dose thiosulfate work
it increases renal elimination of cyanide
how does cyanide work to cause metabolic aciosis
it binds cytochrome oxidases and thus, prevents aerobic metabolism
how does vitamin b12 prevent cyanide toxicitiy
it chelates cyanide
what poison can be used to treat cyanide toxicity
methhemoglobin
what is the byproduct if methemoglobin is used for cyanide toxicity
cyanmethhemoglobin
what drugs can produce methemoglobin
amyl nitrite and sodium nitrite
what is the risk of using thiosulfate for cyanide toxicity
thiosulfate has sulfar that pushes cyanide to metabolize into a renal excreted metabolite…thiocyanide…this in itself is toxic
which patients should not use thiosulfate to treat cyanide toxicity
renal patients bc the thiocyanide that is produced cannot be excreted
what are the symptoms of thiocyanide toxicity
tinnitus, visual changes, seizures
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what ionotrop causes increase cardiac ouput and decrease pulm vascular resistanc
milrinone
what is the tem for a drug able to increase ionotropy and decrease vascular resistance
inodilator
what does milrinone do moa
it is a phosphodiesterase inhibitor
what happens when you inhibit phosphodiesterase
it increases cAMP
what does that increase increase in cyclic amp do to pulm vasculature
it dilates pulm vasculator
what is the mechanism of action of epi
both beta and alpha direct activity
what is baclofen
it is a GABA B Agonist
what is baclofen used for
muscle spasticity
when is baclofen intrathecally indicated
multiple sclerosis, ALS, cerebral palsy, spinal cord injury
when is baclofen indicated for peripheral nerve problems
peripheral, trigeminal, and glossphypharyngeal neuropathy
what is the side effect of baclophen
drowsy, weakness, hypotonia,
what is amytriptyline
it is a tca for antidepressant
what is amitriptyline moa
serotinine reuptake inhibitor
what is fluoxetine
it is a ssri
what is the danger of getting both tca and ssri tx
serotinine syndrome
what is the danger of serotonine syndrome
qt prolongation…inhibition of the perkinje fibers
how do you treat qt prolongation of serotonin syndrome
bicarb
why do you treat prolongation of serotonine syndrome with bicarb
because bicarb helps secrete tca out faster
can you diurese or hemodyalize pt to get rid of tca
no, it is not good as bicarb…bc tca is highly protien bound, its very difficult to excrete the drug these ways
how does bicarb excrete tca fast
it makes tca the neutral form, so it is less protien bound
When does anaphylaxis occur in anesthesia
It occurs a few minutes after induction of anesthesia
What are 3 predictors that the anaphylactic reactions will be severe
It’s rapid onset. Bradycardia. The absence of rash before hemodynamic changes
Whst are 2 labs that need to be drawn to confirm the diagnosis of anaphylaxis
Histamine and tryptase levels
How many different grades of anaphylaxis are there.
There are 4 grades of anaphylaxis
Grade 1 anaphylaxis
Presence of cutaneous mucous signs
Grade 2 anaphylaxis
Multivisceral signs
Grade 3 anaphylaxis
Life threatening multivisceral signs
Grade 4 anaphylaxis
Cardiovascular collapse
When should histamine be collected
Within 30 min for grade 1 and 2. Within 2hr for grade 3 and 4
When. Should tryptase be ordered
Within 15-60 min for grade 1 and 2. Within 30min to2hr for grade 3 and 4
What is the most common med in anesthesia that causes allergies
Muscle relaxants
What is the first medication to give during severe anaphylaxis
Epinephrine. Cardiovascular stability is priority
What is associated with poor outcomes of anaphylaxis.
Late or absence of epinephrine administration
Should fluids be giving during anaphylactic reactions ?
Yes. 50% of intravascular volume could third space secondary to increase vascular permeability
What happens if epi is not able to reverse anaphylaxis instability.
Use vasopressin
If anaphylaxis is not severe, what medications can be used
Hydrocortisone and benadryl
What two nmb causes histamine release
Mivacurium and atricurium
What influences the amount of histamine release from mast. Cells by nmb
The dose and rate of admin
What toxicity is amiodarone associated with
Pulmonary toxicity
What other drug is associated with pulmonary toxicity
Bleomycin
What percent of pt get pulmonary toxicity associated with amiodarone
6%
What is the best predictor of pulmonary toxicity associated with amiodarone
Cumulative dose
What is the mortality rate of pulmonary toxicity secondary to amiodarone
10%
What is associated with patients who get ARDS related to amiodarone
High oxygen fio2 given intraoperatively
Besides pulmonary complications what are other complications associated with amiodarone
Thyrotoxocosis
What complication is associated with doxorubicin
Cardio toxicity
high or low blood to gas partition coefficient will have a faster rate of induction
a lower blood to gas partition coefficient will have a faster rate of induction
what drug can be used PO for chemo related nausea and vomitting
emend aka aprepitant
how does emend work
it is an NK1 antagonist….antagonist of substance P
what are the adverse effects of emend
none
which is more effective, zofran or emend
emend, about 50 times more
when should emend be given
1-3 hours before surgery
can u use zofran even after giving emend
no interactions at all
what are the 3 side effects of protatmine
histamine release, igE mediated allergic reaction, of anaphylactoid reaction
what is ige mediated hypersensitivity
it is a type II hypersensitivity (aka previous exposure to protamine will cause allergic response after a second exposure
what kind of pre-exposure will cause a type II hypersensitivity to protaine
pts getting NPH, protamine zinc insulin, fish allergy
what kind of surgry predisposes pt to protamine type II hypersensitivity
vasectomy
what is an anaphylactoid reaction
it is a type iii hypersensitivity…it is like an allergic reaction (igE mediated) but is actually complement and IgG mediated
what is the risk associated with protamine anaphylactoid reaction
it causes massive pulmonary htn and possible right sided heart faiilure
what is the dose of protamine to fully reverse heparin
0.6 to 1 mg protamine for every 100Units heparin used
what is the most common side effect of protamine
hypotension
does protamine affect platelets
yes, it may decrease the count…but this is transient and clinically insignificant
what two herbal meds may cause irreversible platelet function
garlic and gensing
what herbal medication is taken as a sedative
kava
what happens if acute injestion of kava, what are the anesthestic requirements
decreased anesthestic requirements
what happens if prolong use of kava…what happens to anesthestic requirements
increase anesthetic requirement
what herbal medicine has been used for weight lost
ma huang aka ephedra
wat are adverse effects of mahuang
stroke and cardiac attacks and tachycardia
What is benzocaine toxicity
Methemoglobinemia
What patients are prone to damage from methemoglobinemia
G6PD deficiency, M type hemoglobin, Methemoglobin reductase deficiency
What age in pediatric patient does methemoglobinemia hurt
less than four months
What is the saturation of oxygen methemoglobinemia
84%
Treatment for methemoglobinemia
Methylene blue
Treatment for Cyanide toxicity
Sodium thiosulfate
What treatment for Cyanide toxicity next methemoglobin
amyl nitrite and sodium nitrate,…They make red blood cells form methemoglobin which displaces cyanide from cytochrome oxidase molecules
What treatment for cyanide toxicity and that making vitamin B12
Hydroxocobalamin
Herbal medicine. When should it be stopped before surgery.
If there is unknown data for the herbal medicine, stop it 2weeks before surgery
Herbal medicine. What is ginger used for
Has been used for nausea.
Herbal medicine. What problem can ginger cause.
It is antiplatele and can cause bleeding.
Herbal medicine. What is kava
It is a pepper derivative that can be used for anxiety.
Herbal medicine. How does kava affect anesthesia.
It potentiates benzos
Herbal medicine. Does kava cause and change in bleeding.
No
Herbal medicine. What is St. John’s wart.
It is believed to work like an snri for depression.
Herbal medicine. Is St. John warts an MAOI
No.
Herbal medicine. What effects does St. John’s wart have on the body.
It can inhibit some liver enzymes
Herbal medicine. What anesthetic problem can happen when St. John warts inhibit liver function.
It can make drugs like alfentanil, benzos , and snri increase in the system
Herbal medicine. What does St. John’s wart do to bleeding.
It can become an antagonist to warafin
Herbal medicine. What is valerian.
It is a medicine believed to help with anxiety.
Herbal medicine. When should valerian be stopped prior to surgery
It should not be stopped because it can cause withdrawl
acetylcholinesterase inhibitors. where do they function
at the acetylchoinesterase enzyme
acetylcholineasterase inhibitors. how does neostigmine work at the enzyme
it makes a covalent bond with the enyzme
acetylcholinesterase inhibitors. how does edrophonium work at the enzyme site
it makes an ionic bond with the enzyme
scopolamine patch. what is it used for
post op nausea and vomit
scopolamine patch. when should it be started.
it should be started the night prior to surgery
scopolamine patch. what is the most common side effect
dry mouth
scopoloamine patch. what is the least likely side effect
agitation
atricurium. how is it degraded
1/3 hoffman and 2/3 nonspecific plasma esterases
atricurium. are nonspecific plasma esterases the same as plasma cholinesterases
nope
cisatricurium. how is it degraded
by hoffman elimination
gabapentin. how does it work
voltage gated calcium channel
gabapentin. where on on the voltage gated calcium channel does it work.
the alpha 2 delta subunit
gabapentin. what happens after it binds to the calcium channels
it decreases glutamate and excitation of nociceptive pathways.
GABAa. what drugs work here
benzo, prop, flumazenil, etomidate
voltage gated Na channels. what drugs work here
local anesthetics
phase II block. what characteristics on a twitch monitor
twitchs with fade. fasiculations after post tetanic stimulation
phase II block. who is more prone to get it, adults or children
adults
atypical plasma cholinesterase. what is it aka
pseudocholinesterase, butyrylcholinesterase
alcohol withdrawl syndrome. what is the mortality if withdrawl occurs
up to 35%
alcohol withdrawl syndrom. in operative pt. what is the best treatment for these pt
pre-emptive treatment…identifying the pts at rist and pre-emptive treatment. decreases mortality risk from 35 down to 5%
allergic reaction. what is the cross reactivity between pcn and cephalosporins
10 percent
allergic reaction. if a pt has a pcn allergy, would they be more prone to get allergic reaction after admin of a 1st gen cephalosporin or later gen
1st generation beause they share a side chain of pcn
allergic reaction. how specific is skin testing for allergy to pcn / cephalosporins
95-97% specific
allergic reaction. how sensitive is skin testing for allergy to pcn/ cephalosporin
50% sensitive
amidarone. how long is the half life
about 29 days
amiodarone. how long after discontinuation do u see its effects
up to 45 days
amiodarone. what endo side effect do u see
hyper hypo thyroxicosis can all be seen
amiodarone. what is the most serious consequence of amiodarone use
irreversible pulmonary fibrosis
Organophosphate. What kind of drug is it.
Anticholinesterase.
Organophosphate. What symptoms do you see.
Ach overload. You get bradycardia. Excess gi diarrhea. All your glands secrete. Bronchoconstriction.
Organophosphates. What do you see on EKG.
Qt prolonged because the heart conduction slowed down.
Organophosphates. What is the treatment
Atropine.
Organophosphates. How can you tell it is ortanophosphate on the exam.
Mitosis. Look at the eyes.
Organophosphates. What is it the reciprocal of.
Atropine toxicity.
toxicity treatment. what does methylene blue treat
methhemoglobinemia
toxicity treatment. what does n-acetylcysteine treat
acetaminophen toxicity
toxicity treatment. what does amyl nitrite treat
cyanide toxicity
lithium. what is the effect on muscle blockade
it increases sensitivity to both depol and non depol mm blockers
lithium. what electrolyte effects of li
hypOk and hyper Ca
Lithium. what effects on barbs and benzos
increase effect
remi. how does it help in neuro cases in pt w seizures
when ready to resect seizure focus, a high dose of remi can be given and it can decrease eeg at non seizure area and expose the seziure focus
somatostatin. what med is this used for
carcinoid crisis
dexemetomidine. what is its moa
alpha 2 blocker
dexemetomidine. how does it work similarly to an snri
both snri and dex promote alpha 2 block in the spinal cord…which prevent ascending pathway of nociception
dexemetomidine. what does it do to cpp
drecreases bc it decreases map
