Advanced | Clinical Pharmacology and Anesthesia Part I Flashcards
Maximum dose of LIDOCAINE during Liposuction tumescent technique:
A. 35-55 mg/kg
B. 10 - 5mg/kg
C. 20 - 35 mg/kg
35-55 mg/kg
The maximum acceptable dose of
lidocaine is 35–55 mg/kg when given during liposuction using the tumescent technique.
A 55-kg, 70-year-old woman with mild chronic renal failure is unresponsive 20 hours after an uneventful coronary artery bypass grafting procedure. Anesthetic drugs included fentanyl 3000 mcg, diazepam 35 mg, and pancuronium 20 mg. Which of the following is the most appropriate next step in management?
(A) Administration of edrophonium
(B) Administration of flumazenil
(C) Administration of naloxone
(D) CT scan of the head
(E) Measurement of core body temperature
(B) Administration of flumazenil
Metabolism of benzodiazepines occurs largely in the hepatic cytochrome P450 system via oxidation and glucuronic conjugation.
The metabolized drug
is then renally excreted. Some drugs, such as diazepam, have
pharmacologically active metabolites (i.e., desmethyldiazepam, 3-
hydroxydiazepam) with long elimination half-lives that lead to a prolonged duration of action, especially in patients with renal failure.
Barash | 9th edit
Which of the following statements concerning neuroleptic malignant syndrome is true?
(A) It does not respond to dantrolene therapy
(B) It is inherited as an autosomal trait
(C) It is not triggered by
succinylcholine
(D) It occurs after long-term use of L-dopa
(E) The halothane-caffeine contracture test is negative in susceptible patients
(C) It is not triggered by
succinylcholine
Which of the following is an effect of metoclopramide?
(A) Decreased lower esophageal sphincter tone
(B) Decreased MAC for enflurane
(C) Extrapyramidal signs
(D) Increased gastric pH
(E) Relief of intestinal obstruction
(C) Extrapyramidal signs
Which of the following is a side effect of beta-adrenergic blockade?
(A) Cerebral vasodilation
(B) Decreased left ventricular filling pressures
(C) Hypokalemia
(D) Increased airway resistance
(E) Uterine relaxation
(D) Increased airway resistance
Compared with the response of a normal patient, administration of a bolus dose of pancuronium (0.15 mg/kg) to a patient with cirrhosis and ascites would be associated with
(A) longer duration
(B) more rapid onset
(C) more intense block
(D) more difficult reversibility
(E) similar pharmacokinetics
(A) longer duration
Compared with thiopental, methohexital is characterized by
(A) better absorption after rectal administration
(B) greater protein binding
(C) greater hepatic clearance
(D) larger volume of distribution
(E) more complete biotransformation
(C) greater hepatic clearance
In a patient taking a beta-adrenergic blocker, the drug most likely to produce atrioventricular junctional block is:
(A) diltiazem
(B) fentanyl
(C) halothane
(D) nifedipine
(E) verapamil
(E) verapamil
Which of the following statements concerning the metabolism of atracurium is true?
(A) It is related to cardiac output
(B) It is decreased by hyperthermia
(C) It is unaffected by increasing age
(D) It is decreased by low plasma cholinesterase activity
(E) It is decreased in renal failure
(C) It is unaffected by increasing age
TRUE or FALSE
A patient with HYPERTHERMIA and ALKALOSIS will slow down the process of Hoffman elimination?
FALSE!
Hypothermia and Acidosis slows down the Hofmann elimination
TRUE or FALSE
A patient with hepatic cirrhosis will have an altered clearance of LAUDANOSINE?
FALSE!
Laudanosine is 70% excreted in the bile and the rest is via urine. Patient with biliary obstruction will have an impaired clearance of this byproduct.
Which of the following produces higher LAUDANOSINE as a byproduct of Hofmann elimination?
A. Atracurium
B. Cis-atracurium
C. Mivacurium
A. Atracurium
The reason is potency. Cis-atracurium is 4-5 times more potent than atracurium thus 5 times less LAUDANOSINE is produced.
More potent means less LAUDANOSINE!
Desflurane is delivered using a vaporizer that contains internal heaters because
(A) heat decreases the drug’s viscosity
(B) heat reduces thermal loss in the patient
(C) heat increases the drug’s oil-gas partition coefficient
(D) heat prevents fluctuations of vapor pressure
(E) it does not vaporize adequately at room temperature
(D) heat prevents fluctuations of vapor pressure
During nitrous oxide anesthesia, which of the following expands most rapidly?
(A) Air bubble in the blood
(B) Air in the intestine
(C) Endotracheal tube cuff
(D) Pneumothorax
(E) Sulfahexafluoride bubble in the vitreal cavity
(A) Air bubble in the blood
Compared with morphine 5 mg administered epidurally at T12, morphine 5 mg administered intravenously is associated with
(A) greater incidence of urinary retention
(B) less intense analgesia
(C) less nausea and vomiting
(D) longer duration of analgesia
(E) longer time to maximum analgesia
(B) less intense analgesia
Plasma morphine concentrations after rapid IV injections do not correlate closely with the drug’s pharmacologic activity, likely due to the delay in transit of morphine across the blood–brain barrier.
Cerebrospinal fluid (CSF) concentrations of morphine peak 15 to 30 minutes after IV injection and decay more slowly than plasma concentrations. As a result, the analgesic and ventilatory depressant effects of morphine may not be evident during the initial high plasma concentrations after IV administration
of the opioid.
Spontaneously breathing enflurane at 1 MAC causes increased:
(A) airway resistance
(B) diaphragm function
(C) carbon dioxide production
(D) intercostal muscle function
(E) physiologic dead space
(E) physiologic dead space
Compared with epidural administration of hydrophilic opioids, epidural administration of lipophilic opioids is associated with:
(A) earlier onset of pruritus
(B) greater motor block when combined with local anesthetics
(C) higher incidence of delayed respiratory depression
(D) lesser sensitivity to reversal of analgesia by naloxone
(E) slower onset of analgesia
(A) earlier onset of pruritus
In a 35-year-old patient, which of the following is associated with an increased duration of clinical narcosis following infusion of a total dose of 10 mg/kg thiopental over three hours?
(A) Alcoholism in remission
(B) Asthma
(C) Fever
(D) Obesity
(E) Use of appetite suppressants
(D) Obesity
The time required for the plasma concentration of thiopental to decrease 50% after discontinuation of
a prolonged infusion (context-sensitive half-time) is lengthy.
The drug is sequestered in fat and skeletal muscle and then it reenters the circulation and prevents the plasma concentration from dropping rapidly.
An infant was administered with Thiopental during induction of anesthesia. In comparison with adult, pediatric patients will be expected to have:
A. Rapid hepatic clearance of thiopental
is expected in infants compared with that of an adult
B. Protein binding is expected to be higher in adults relative to the matured Albumin and Alpha 1 glycoprotein
C. Recovery after large or repeated doses of
thiopental may be slower for infants and children than for adults
D. longer elimination half-time is expected in pediatric patients
B. No difference in protein binding is expected
In pediatric patients, the elimination half-time of thiopental is shorter than in adults.
This is due to more rapid hepatic clearance of thiopental by pediatric patients. Therefore, recovery after large or repeated doses of
thiopental may be more rapid for infants and children than for adults.
Protein binding and Vd of thiopental are not different in pediatric and adult patients.
Elimination half-time is prolonged during pregnancy because of the increased protein binding of thiopental.
Compared with dopamine, dobutamine
(A) is more useful in patients taking monoamine oxidase inhibitors because it depends on the release of norepinephrine for its effect
(B) is more useful in patients in right heart failure because it does not increase pulmonary vascular resistance
(C) has no positive chronotropic response
(D) induces diuresis without increasing cardiac output
(E) in doses greater than 10 mcg/kg/min increases systemic vascular resistance more than similar doses of dopamine
(B) is more useful in patients in right heart failure because it does not increase pulmonary vascular resistance
During anesthesia with nitrous oxide 65% in oxygen, fentanyl, and pancuronium, nitroprusside is administered to decrease arterial pressure to 85/50 mmHg. A decrease in PaO2 from 120 to 65 mmHg is most likely caused by:
(A) cyanide toxicity
(B) depressed cardiac output
(C) mild hypercarbia
(D) metabolic acidosis
(E) pulmonary vasodilation
(E) pulmonary vasodilation
Nitroprusside as a vasodilator is contraindicated in MYOCARDIAL ISCHEMIA due to:
A. Coronary steal phenomenon
B. Risk of cyanide toxicity
C. Baroreceptor-mediated reflex induces Tachycardia
D. Increased risk of hypoxia due to methemoglobinemia
A. Coronary steal phenomenon
Unlike nitroglycerin, sodium nitroprusside is relatively contraindicated in patients with acute myocardial ischemia because the drug causes abnormal redistribution of coronary blood flow away from ischemic myocardium (a phenomenon known as CORONARY STEAL).
The SNP may increase the area of damage associated with a myocardial infarction through a phenomenon called “coronary steal.” The SNP dilates resistance vessels in non-ischemic myocardium, resulting in diversion of blood flow away from ischemic areas where collateral blood vessels are already maximally dilated. Decreases in diastolic blood pressure produced by SNP may also contribute to myocardial ischemia by decreasing coronary perfusion pressure and associated coronary blood flow.
Which of the following metabolite is the main cause of the renal insufficiency seen in patients given NTP(Sodium Nitroprusside):
A. Cyanide
B. Thiocyanate
C. Methemoglobin
D. Sulfur
B. Thiocyanate
Metabolism of sodium nitroprusside produces cyanide, which binds with cytochrome
oxidase to inhibit aerobic metabolism, with hemoglobin to form methemoglobin, and with sulfur to form thiocyanate.
The latter metabolite may accumulate in patients with renal insufficiency and produce neurologic
complications including delirium and seizures.
Which of the following is the primary metabolism of Norepinephrine?
A. Kidney
B. Liver
C. Lungs
D. Heart
C. Lungs
A 70-year-old man who has just undergone an abdominal aortic aneurysm repair under halothane anesthesia develops hypertension, dyspnea, and cyanosis shortly after awakening in the recovery room. Administration of furosemide 20 mg intravenously improves the cyanosis within 10 minutes. This immediate effect of furosemide is BEST explained by:
(A) inotropic effect from electrolyte shifts
(B) decreased preload through diuresis
(C) increased peripheral venous capacitance
(D) decreased pulmonary vascular resistance
(E) increased coronary blood flow
(C) increased peripheral venous capacitance
Furosemide is a loop diuretic that inhibits the Na-K-2Cl symporter in the loop of Henle. It exerts direct vasoactive effects, as well as hormonally mediated changes via release of renin, angiotensin II, and prostaglandins. These result in arterial vasoconstriction and venous vasodilation, as well as diuresis.
In heart failure patients, it has been demonstrated that venous capacitance and blood flow in the calf increased within 5 minutes after administration of furosemide, an effect that preceded diuresis by 25 minutes, indicating direct venodilatory effects.
It was also noted that there was a reduction in right atrial pressure and PCWP, indicating an acute reduction in preload that was not attributable to diuretic effects of furosemide.
- Therefore, the acute venodilatory effects of furosemide may be a larger contributor in the early clinical improvement of acute heart failure symptoms than diuresis.
Ref: Uptodate
Each of the following would be expected after preoperative oral administration of clonidine EXCEPT
(A) bradycardia in the absence of surgical stimulation
(B) decreased requirement for inhalational anesthetics
(C) decreased requirement for opioid anesthetics
(D) decreased response to exogenous epinephrine
(E) sedation
(D) decreased response to exogenous epinephrine
Clonidine is rapidly absorbed after oral administration and reaches peak plasma concentrations within 60 to 90 minutes.
Rebound hypertension is most likely to occur in patients who were receiving greater than 1.2 mg of clonidine daily.
- The increase in systemic blood
pressure may be associated with a greater than 100% increase in circulating concentrations of catecholamines and intense peripheral vasoconstriction.
In a patient who is receiving nitroglycerin intravenously after a coronary artery operation, peripheral oxygen saturation is 85% and PaO2 is 200 mmHg. The most appropriate management is administration of:
(A) exchange transfusion
(B) hydroxocobalamin
(C) methylene blue
(D) pure oxygen at 3 atmospheres
(E) thiocyanate
(C) methylene blue
The definitive treatment of methemoglobinemia is the administration of methylene blue 1-2 mg/kg intravenous over 5 minutes.
The dose can be repeated in an hour after the initial dose.1
Methylene blue acts as an electron donor reducing oxidized Hb.
Methylene blue can also precipitate serotonin syndrome in patients taking selective serotonins reuptake inhibitors (SSRIs) and should be avoided in these patients
During therapy for eclampsia, toxic blood levels of magnesium sulfate can be distinguished from therapeutic levels by the presence of:
(A) diminished knee jerk reflex
(B) a widened QRS complex on EKG
(C) fetal tachycardia
(D) maternal drowsiness
(E) uterine rigidity
(B) a widened QRS complex on EKG
Which of the following is associated with the application of a transdermal fentanyl patch?
(A) Achievement of a peak plasma level within one hour
(B) Continued uptake after patch removal
(C) Dose-independent plasma clearance
(D) Tachyphylaxis when used for cancer pain
(E) Naloxone-resistant toxicity
(B) Continued uptake after patch removal
Transdermal fentanyl preparations delivering 75 to 100 μg/hour result in peak plasma fentanyl concentrations in about 18 hours that tend to remain stable during the presence of the patch, followed by a decreasing plasma concentration for several hours after removal of the delivery system.
Transdermal fentanyl systems applied before the induction of anesthesia and left in place for 24 hours decrease the amount of parenteral opioid required for postoperative analgesia.
Stoelting Pharmacology | 6th edit
A patient on an IV heparin infusion develops platelet antibodies and a decreasing platelet count which agent should you use for bypass:
A. Bivalirudin
B. Heparin
C. Fondaparinux
D. Danaparoid
E. Clexane
A. Bivalirudin
Bivalirudin
Heparin/protamine contraindication for CPB!
- Bivalirudin is first choice
- Comes in 250 mg powder vials; dilute 1 vial in 50 mg saline.
- Bolus dose is 1-1.5 mg/kg (0.3 mL/kg) plus 50 mg into the pump prime then an infusion at 2.5 mg/kg/hr (0.5 mL/kg/hr).
- Doses should be reduced in renal failure.
- Check response with kaolin ACT >2.5 x baseline
- No antidote/reversal except dialysis
- Argatroban another option but you can’t monitor
You are anaesthetising a 6-month old infant for repair of a VSD. You perform an inhalational induction with 8% sevoflurane and 50% nitrous oxide. Several minutes later, whilst trying to secure IV access, the infant’s oxygen saturations fall to 85%. The most appropriate next step in management.
a) give fluid bolus
b) change from sevoflurane to isoflurane
c) apply CPAP
d) reduce the FiO2
e) reduce sevoflurane
e) reduce sevoflurane
reduce sevoflurane thereby Improving the SVR –> reverses shunt
100kg patient paralysed with rocuronium. What is the dose of sugammadex to reverse paralysis with PTC of 2 and TOFC 0:
A. 150 mg
B. 200 mg
C. 400 mg
D. 800mg
E. 1600 mg
C. 400 mg
2yo child, 12kg for orchidopexy. You perform a caudal and use 0.2% ropivocaine. How much do you give to provide post-op analgesia?
a) 3ml
b) 6ml
c) 12ml
d) 18ml
e) 24ml
c) 12ml
12 mL
Typical dose is 1 mL/kg 0.2% ropivacaine with 1 mcg/kg clonidine
This leaves 0.5 mL/kg 0.2% ropivacaine for infiltration
4 year old having a GA for bone marrow biopsy in a suspected case of ALL. Which of the following antiemetic should be avoided?
A. Droperiodol
B. Ondansetron
C. Dexamethasone
D. Metaclopramide
E. Cyclazine
C. Dexamethasone
Contraindicated due to possibility of tumor lysis syndrome
Category 1 <15 min LSCS in a primip with multiple sclerosis. How do you provide anaesthesia?
A. Remove epidural and give spinal anaesthesia with heavy bupivacaine and fentanyl
B. Top up epidural with 20 mL ligocaine 1% and adrenaline
C. Top up epidural
D. RSI and GA
E. Continuous Spinal Epidural
C. Top up epidural
Idarucizumab reverses the anticoagulant effect of:
A. Dabigatran
B. Clopidogrel
C. Apixaban
D. Warfarin
A. Dabigatran
- Idarucizumab reverses dabigatran
- Andexanet alfa reverses rivaroxaban and apixaban
In planning the induction of anesthesia in a morbidly obese patient, the total body weight should be used to calculate the dose of:
A. Suxamethonium
B. Rocuronium
C. Propofol
D. Fentanyl
E. Alfentanil
A. Suxamethonium
The pharmacologic property of XENON which is responsible for its analgesic property is:
A. NMDA inhibition
B. GABA-A inhibition
C. Analgesic effect at the spinal cord level
D. Blunting of pain receptors at the cerebral cortex
A. NMDA inhibition
Xenon provides some degree of analgesia. Its blood:gas partition coefficient is 0.115, and unlike the other potent volatile anesthetics (except methoxyflurane), xenon provides some degree of analgesia. This action is likely due to N-methyl-D-aspartate (NMDA) receptor inhibition.
Inhibition of labor by terbutaline causes each of the following maternal side effects EXCEPT
(A) hyperkalemia
(B) hypotension
(C) ventricular dysrhythmias
(D) hyperglycemia
(E) pulmonary edema
(A) hyperkalemia
One of the side effects of terbutaline is hypokalemia
Each of the following is a recognized complication during a transurethral resection for which glycine is used as an irrigant EXCEPT
(A) disseminated intravascular coagulopathy
(B) hemolysis
(C) hyperammonemia
(D) shoulder pain
(E) transient blindness
(B) Hemolysis
Which of the following is NOT a recognized complication during a transurethral resection when distilled water is used as an irrigant?
A. Hemolysis
B. Hemoglobinemia
C. Hemoglobinuria
D. Hyponatremia
E. Osmotic diuresis
E. Osmotic diuresis
- On the contrary, Sorbitol is highly associated with osmotic diuresis.
Which of the following irrigant has the LEAST propensity in the development of TURP syndrome?
A. Glycine 1.5%
B. Mannitol 5%
C. Distilled water
D. Sorbitol 3.3%
A. Glycine 1.5%
The alveolar concentrations of anesthetics increase more rapidly in children than in adults because of a greater:
(A) blood volume (per kg body mass)
(B) cardiac index
(C) MAC
(D) ratio of alveolar ventilation to functional residual capacity
(E) tidal volume (per kg body mass)
(D) ratio of alveolar ventilation to functional residual capacity
Which of the following conditions is a contraindication to the use of succinylcholine?
(A) Burns of 50% body surface area occurring 12 hours ago
(B) Cirrhosis
(C) Myotonic dystrophy
(D) Seizure disorder
(E) Spinal cord transection within the past six hours
(C) Myotonic dystrophy
Although it should be avoided in patients with Myotonic dystrophy, there are instances where in depolarizing NMB is better than non-depolarizing, including myotonic dystrophy.
- Cirrhotic patients exhibit decreased pseudocholinesterase activity hence Succinylcholine is a relative contraindication.
Compared with epidural administration of hydrophilic opioids, epidural administration of lipophilic opioids is associated with
(A) earlier onset of pruritus
(B) greater motor block when combined with local anesthetics
(C) higher incidence of delayed respiratory depression
(D) lesser sensitivity to reversal of analgesia by naloxone
(E) slower onset of analgesia
(A) earlier onset of pruritus
In a patient who is to undergo clipping of a cerebral aneurysm, an advantage of isoflurane over nitroprusside for induction of hypotension is:
(A) better maintenance of cardiac output
(B) better maintenance of cerebral blood flow
(C) greater decrease in cerebral oxygen consumption
(D) greater decrease in afterload
(E) more rapid titration of systemic blood pressure
(C) greater decrease in cerebral oxygen consumption
After termination of cardiopulmonary bypass, a patient who is chronically digitalized receives digoxin 0.5 mg in error. An ECG shows sinus bradycardia with intermittent sinus arrest; blood pressure is 90/60 mmHg. Which of the following drugs is contraiindicated in this patient?
(A) Atropine
(B) Calcium chloride
(C) Ephedrine
(D) Magnesium sulfate
(E) Phenylephrine
(B) Calcium chloride
Digoxin inhibits the sodium-potassium ATPase pump, causing potassium to become trapped extracellularly, leading to hyperkalemia. Intravenous calcium gluconate is commonly used as a first-agent medication for hyperkalemia presenting with ECG changes to antagonize potassium’s cardiac effect.
However, there was mixed evidence that the interaction of intravenous calcium with digoxin toxicity could cause a “stone heart.” The idea was that adding calcium, when there was already an excess within the myocytes, led to uncontrolled calcium-troponin C binding, further depleting ATP and forming rigor bonds.
The interplay between digoxin toxicity and stone heart syndrome and their pharmacological effects on cardiac physiology is crucial for clinical decision-making and improving patient outcomes.
Which of the following drugs exerts a vasoconstrictor effect by blocking the reuptake of norepinephrine at the neuronal synapse?
(A) Cocaine
(B) Dopamine
(C) Ephedrine
(D) Metaraminol
(E) Phenylephrine
(A) Cocaine
- Cocaine produces sympathetic nervous system stimulation by blocking the presynaptic uptake of norepinephrine and dopamine, thus increasing their postsynaptic concentrations.
Because of this blocking effect, dopamine remains at high concentrations in the synapse and continues to affect adjacent neurons, producing the characteristic cocaine “high.”
Chronic exposure to cocaine is postulated to affect adversely dopaminergic function in the brain due to dopamine depletion.
A 20-year-old male is scheduled for emergency inguinal surgery and has a significant history of cocaine use. At the pre-operative area, he complaints of chest pain. Which of the following anesthetic agents would least likely reverse the cocaine-induced chest pain?
A. Phentolamine
B. NTG
C. Na nitroprusside
D. Beta-blockers
D. Beta-blockers
Nitroglycerin has been used to treat cocaine-induced myocardial
ischemia. β-Adrenergic blockade accentuates coronary artery vasospasm in the setting of acute cocaine overdose.
Whether β-adrenergic
blockade is harmful for coronary vasospasm in the setting of chronic cocaine use is not known. Furthermore, administration of β-blocking drugs in the presence of catecholamine-induced hypertension and tachycardia has
been associated with profound cardiovascular collapse and cardiac arrest that is unresponsive to aggressive cardiopulmonary resuscitation.
Thus, β blockers should be used with caution. In this situation, administration of a vasodilating drug such as nitroprusside may be the safest intervention.
Stoelting’s Pharmacology | 6th edit
Succinylcholine can be administered safely to a patient with:
(A) amyotrophic lateral sclerosis
(B) cerebral palsy
(C) a pelvic crush injury sustained two weeks ago
(D) a 20% body surface area burn sustained 10 days ago
(E) hemiparesis one month after a cerebrovascular accident
(B) cerebral palsy
