ALL Flashcards
What does the glomerulus do
filtration
What does the proximal tubule do
reabsorption (mostly NaCL)
- also secretes hydrogen, foreign substances, organic anions and cations
- isotonic
Carbonic Anhydrase Inhibitors and osmotic diuretics work here
What does the loop of Henle do
concentrates urine
-isotonic, hypertonic, hypotonic
Descending Loop: NaCl diffuses in, water reabsorbed
Ascending Loop: NaCl actively reabsorbed, water stays in
Loop diuretics work here
What does the distal tubule do
Reabsorption of Nacl, water (ADH required), bicarb
- isotonic or hypotonic
Thiazides work here
This is where blood pressure changes are made - thiazides work here and they work on decreasing pressure…WHERE THE RAAS system begins
What does the collecting duct do
final concentration
- reabsorbs water (ADH required), NaCL
What is the GFR for CKD diagnosis
less than 60 for over 3 months with/without kidney damage
Are longer intervals between HD and surgery associated with a higher risk of post-op mortality?
YES
What BUN/SCR is dehydration?
BUN/SCR > 20
1.5 SCR or GFR drop 25%. risk
2. 50. injury
3 75. failure
urine .5. 6 hrs
.5. 12 hrs
under .3. for 24 or no urine for 12
Where does each group of diuretic work?
Proximal tubule - Carbonic anhydrase inhibitors AND osmotic diuretics
Loop of Henle - Loop diuretics
Distal Tubule - Thiazides
Distal tubule / collecting duct - potassium sparing
Are carbonic anhydrase inhibitors used as diuretics these days?
Not really - Acetazolamide (Diamox) is used off label for metabolic alkalosis (commonly happens when “over-diuresing” CHF patients)
What is an interesting use for Acetazolamide?
Altitude sickness
What do carbonic anhydrase inhibitors do?
Inhibit CA which inhibits H+ secretion in the proximal tubule. Bicarb and sodium are blocked from reabsorption
Do carbonic anhydrase inhibitors cross the BBB?
YES
What do osmotic diuretics do (mannitol and urea)
Uncouples Na and H2O reabsorption by increasing the osmotic gradient in the proximal tubule. Na reabsorption initially, but H2O is not, leading to decreased Na reabsorption distally.
They “pull water” and increase intravascular volume.
Osmotic diuretics primarily inhibit water reabsorption in the proximal convoluted tubule and the thin descending loop of Henle and collecting duct, regions of the kidney that are highly permeable to water.
Osmotic diuretics also extract water from intracellular compartments, increasing extracellular fluid volume. Overall, urine flow increases with a relatively small loss of Na+. In fact, urine osmolarity actually decreases.
What are Mannitol’s different uses?
Prophylaxis against acute renal failure (ARF)…loop diuretics are too
Differential diagnosis of acute oliguria (if the patient responds to mannitol, they are just dehydrated…if not, they have actual renal damage)
Treatment of increased intracranial pressure (ICP)
Decreasing intraocular pressure (IOP)
Is mannitol REALLY nephroprotective? What does current research say about it?
NOPE.
No better than plain saline pre-radiocontrast dye
EXCEPT: renal transplant surgery
Do you need an intact BBB when using mannitol?
YES
If not, it will pull water into the brain and increase ICP, which is the opposite of what we want
Urinary ph NOT altered by mannitol
What are dangerous side effects of mannitol?
Pulmonary edema, hypovolemia, hypernatremia
electrolyte disturbances, plasma hyperosmolarity d/t water and NaCl secretion (hypernatremia)
What electrolyte abnormality can mannitol create?
Hypernatremia from excess water loss
What negative side-effect is urea associated with?
Venous thrombosis and tissue necrosis after extravasation (not seen with mannitol)
What is loop diuretics MOA?
Inhibits Na and Cl reabsorption in the ascending loop and to a lesser extent in the proximal tubule
Which two diuretics are nephroprotective?
mannitol (osmotic) and loop diuretics (furosemide)
What are loop diuretics clinical uses?
Mobilization of edema fluid due to renal, hepatic, or cardiac dysfunction
Treatment of increased ICP
Treatment of hypercalcemia
Differential diagnosis of acute oliguria
What happens when you take NSAIDS while on a loop diuretic?
Furosemide-induced increases in renal blood flow are inhibited by NSAIDs resulting in an attenuated diuretic effect
What is braking phenomenom?
Acute Tolerance (Braking Phenomenon) – ceiling effect with diuretic where giving more doesn’t increase outcome but can increase side effects.
Associated with loop diuretics
Loop diuretics electrolyte side-effects
All low basically
Hypokalemia
Hypochloremia
Hyponatremia
Hypomagnesemia
Hypokalemic Metabolic alkalosis (thiazides also cause this)
Which diuretic can cause deafness?
Loop diuretics
Which type of medication are loop diuretics cross-sensitive to?
Sulfa antibiotics, sulfonylureas, thiazide diuretics
Do antibiotics increase the chance of nephrotoxicity when using loop diuretics?
YES, for aminoglycosides and cephalosporins
- penicillins and furosemide together are associated with allergic interstitial nephritis
What is thiazides (chlorothiazide, hydrochlorothiazide) MOA?
Compete for the Na-Cl cotransporter in the distal tubule to inhibit reabsorption. Inhibit only urinary diluting capacity, not concentrating capacity.
Which electrolyte do thiazide diuretics INCREASE?
calcium (increased calcium reabsorption)
What are thiazides clinical uses?
hypertension and mobilization of edema
Thiazides also can cause arrhythmias along with loop diuretics because of the hypokalemia
Thiazides electrolyte side-effects
Hyperglycemia
Hyperuricemia
Hypercalcemia
Decreased renal or hepatic function
Decreased intravascular volume
metabolic alkalosis with chronic administration
Are thiazides associated with hyper or hypo blood sugar and uric acid?
HYPERglycemia and HYPERuricemia
Do potassium-sparing diuretics cause hyperglycemia and hyperuricemia like thiazides?
NOPE
What are the MOA of potassium-sparing diuretics?
Amiloride and Triamterene: inhibit Na reabsoprtion induced by aldosterone. Inhibit active counter transport of Na and K in the collecting duct. MESS UP THE the Na-K-ATPase pump
Spironolactone and Eplerenone: competes for aldosterone receptor sites in the distal tubule to block Na reabsorption and K secretion. Competitive inhibitors of aldosterone
What is the main side-effect of potassium-sparing diuretics and what makes this issue worse?
HYPERKALEMIA
Made worse when also taking NSAIDs, Ace inhibitors (i.e. lisinopril), Beta-blockers
Which two diuretics cause hypokalemic, hyperchloremic metabolic alkolosis?
Thiazides and loop diuretics
EKG changes with hyperkalemia
Tall peaked T wave
Loss of P wave
Widened QRS with tall T wave
Why do we give calcium when correcting hyperkalemia?
Stabilizes the heart and lowers the threshold potential of the myocardium.
Caution in patients who are on digoxin – calcium has been reported to worsen the myocardial effects of digoxin toxicity..could use Mg as an alternative to stabilize the myocardium
Treatment for hyperkalemia
C = Calcium (cardiac stabilizer)
B = inhaled beta2 agonists (intracellular shift)
I = Insulin (followed by..)
G = Glucose (given with insulin)
K = Kayexalate (mainly chronic RF)
D = Diuretics (renal elimination)
ROP = Renal unit for dialysis Of Patient
What are some causes of hyponatremia?
Loss of body fluid, thiazides, loops, CHF, SSRIs, Carbamazepine, Lithium, Liver disease
Hyponatremia correction rates
Severe symptomatic hyponatremia: 6-12 mEq/L in the first 24 hrs and 18 mEq/L or less in 48 hrs
Chronic hyponatremia: 0.5 mEq/L/hr with max change of 8-10 mEq/L in a 24 hr period
What is calcium dependent on?
Albumin
What are some causes of hypercalcemia?
Hyperparathyroidism
Chronic renal failure or vitamin D deficiency
Vitamin D intoxication
Malignancy
Diuretics (usually mild)
Lithium
What antibiotics can cause nephrotoxicity when using with loop diuretics?
Aminoglycosides and cephalosporins
Which antiepileptic is the treatment of choice for status epilepticus according to most recent treatment guidelines?
lorazepam (Ativan)
Order of meds to give for seizure
- Benzodiazepine
If benzo not available try: phenobarbital IV, diazepam rectal, nasal or buccal midazolam
- Second phase: fosphenytoin IV, valproic acid IV, levetiracetam IV
- Repeat of any second line therapy
Anesthetic doses of thiopental, midazolam, pentobarbital, or propofol
Which sodium channel blocker has the most side-effects, drug interactions, and causes hyponatremia?
Carbamazepine
Which sodium channel blocker induces its own metabolism (reduces its own levels)?
Carbamazepine
Which sodium channel blocker has unpredictable pharmacokinetics and has similar antiarrhythmic properties as lidocaine?
Phenytoin (fosphenytoin is the oral prodrug)
Which sodium channel blocker causes gingival hyperplasia, arrythmias due to class 1B antiarrythmic association, and can cause cleft palate/congenital heart disease/slowed growth rate/mental deficiency if given during pregnancy?
Phenytoin
Which sodium channel blocker, when given with depakote, can cause TERRIBLE rash that is life-threatening and basically Steven-Johnson X 1,000?
Lamotrigine (lamictal)
Lam”oh my god”trigine
Which sodium channel blocker has the highest rates of kidney stones?
Zonisamide
Kidney ZONES…zonisamide!
KIDNEYZONISAMIDE
STONEISAMIDE
Which sodium-channel blocker has the best safety profile?
Lacosamide
La”coast”amide
Which benzodiazepine has the highest rates of withdrawal?
Clobazam (Onfi)
Which benzo is the most and least lipophilic?
clobazam and temazepam
______ is only available through a very specific program with REMS monitoring because of risk of permanent vision loss,
Vigabatrin
Vi”sual”gabatrin
What is gabapentin mostly used for?
Neuropathic pain or anxiety. Helps reduce pain post-operatively
Which combination of medications greatly increases the risk of hyponatremia?
SSRIs and Carbamazepine (Tegretol)
What is a fairly common yet weird side-effect of pregabalin?
Difficulty walking, gait abnormalities
This seizure medication may raise ammonia levels leading to possible confusion, agitation, and delirium
Valproic Acid
Valproic A”mmonia”cid
With in utero exposure, ______ can lower IQ in children compared to other anti-epileptics (category D-X)
Hint: it also raises ammonia levels
Valproic Acid
“Valprammonia”
Which anticonvulsant can make you feel like your mind and body are disconected?
Topiramate
Top”off”iramate
This seizure med can cause SEVERE cognitive impairment? Example of professors friend who would forget everything
Levetiracetam (keppra)
What the fuck does dantrolene do
Blocks ryanodine channel, reduces Ca ++ release from SR
Med of choice for malignant hyperthermia
Which class of antidepressant has significant anticholinergic properties?
TCAs- tricyclic antidepressants
Tricyclic anticholinergic antidepressants..
What do you give for a tricyclic antidepressant overdose?
NaHCO3 d/t metabolic acidosis, supportive therapy
What do all anti-depressants have BLACK BOX WARNING FOR?
Suicidal ideations
Which SSRI has a black box for QT prolongation
Citalopram (Celexa)
______ are the most highly sedating anti-depressants
5HT2A antagonist (trazadone is an example)
_______ is used for Pseudobulbar affect (laughing inappropriately)
Nuedexta
“Nuts”dexta
Which generation of antipsychotics are supposed to be safer, but aren’t really?
2nd
_______ have a black box warning for dementia related death, agranulocytosis
Antipsychotics
Levodopa is a ______, and carbidopa is _______
Levodopa = dopamine precursor
Carbidopa = false dopamine
What are the two classes of Alzheimer’s Medications
Acetylcholinesterase Inhibitors
NMDA receptor antagonists
What is the most common side effect of AChEi
Rest/digest side effects
Bradycardia
Loose stools
OAB
What do alzheimers meds do to succinylcholine and other NMB?
POTENTIATE succinylcholine
REDUCE blockade of other NMB
Antipsychotics - too much dopamine
Parikinsons - not enough dopamine
Yep
Carbidopa/Levodopa (Sinemet) improves Parkinson’s symptoms via which mechanism of action?
Dopamine receptor agonist
One way to predictably reduce the incidence of post-operative delirium is to use lighter sedation.
FALSE
Aricept (Donepezil), a medication used for Alzheimer’s disease, may antagonize the effects of succinylcholine.
FALSE
Which seizure medication has similar antiarrhythmic properties as Lidocaine?
Phenytoin (Dilantin)
An FDA safety communication from 12/2019 stated that gabapentinoids (like Gabapentin) increase the risk of which side effect when combined with opiates?
Respiratory depression
Is bactericidal better than bacteriostatic?
Nope! Equal
Do greater concentrations kill bacteria faster or in greater numbers?
NOPE
Does vancomycin work on gram-positive or gram-negative bacteria?
gram-positive
What are the 3 main nosocomial infections?
Urinary
Respiratory
Blood
What devices are associated with nosocomial infections?
Ventilator
Vascular access catheter
Urethral catheter
Which central lines cause the most infections?
Femoral> I.J. >Subclavian
Primary cause of c-diff?
clindamycin
What is the treatment for c-diff?
Oral vancomycin
Dificid (fidaxomicin)- similar cure rates as vanco, reduced recurrence for moderate to severe infection
What are the risk factors for c-diff?
Antimicrobial use
Acid suppressant therapy
Inappropriate handwashing and cleaning techniques
Do you always need surgical antibiotic prophylaxis?
NO.
Also, usually not necessary to continue past the 1st Post-op day
Usually use 1st generation cephalosporin (cefazolin)
Wound classification
Class I: Clean (1.3-2.9%)
Atraumatic
No break in sterile technique
Respiratory, G.I., and G.U. tracts not entered
Class II: Clean-Contaminated (2.4-7.7%)
Surgery in areas known to harbor bacteria
no spillage of contents
Class III: Contaminated (6.4-15.2%)
Major break in sterile technique
Surgery on traumatic wounds
Gross G.I. spillage
Entrance into an infected biliary or G.U. tract
Class IV: Dirty-Infected (7.1-40%)
Infection existed before the surgery
Old wound with devitalized tissue
Perforated viscera
Is prophylaxis for fungal infections proven to always work?
Efficacy of prophylaxis is difficult to prove
When do you give ancef, and when do you give vanco for prophylaxis?
Ancef 60 minutes
Vanco 120 minutes
Is increasing duration of antimicrobial prophylaxis associated with higher odds of AKI and C difficile infection in a duration-dependent fashion?
YES. Increasing prophylaxis is bad.
What is the half life of cefazolin, clindamycin, and vanomycin?
Cefazolin: 2 hrs, so dose at 4hrs
Clindamycin: 3 hrs, so dose at 6 hrs
Vancomycin: 12 hours..so..unecessary
Do beta-lactamase Inhibitors have any antimicrobial effect on their own?
NO
Which group of antibiotics causes Jarisch-Herxheimer rxn – looks like a tick infection (high fevers and rash)?
Penicillins
Do patients with a penicillin allergy have an increased risk of SSI?
YES, about 50% higher
Which antibiotic can you give if someone has a penicillin allergy?
Cefazolin
Vancomycin
Which infections are higher in patients with a penicillin allergy?
MRSA and C.difficile
What are the two strongest cephalosporins that cover basically everything?
Ceftaroline (Teflaro) and Cefiderocol (Fetroja)
What is the drug of choice for MRSA?
Vanco
Side effects of vanco?
Red-Man, nephrotoxicity, ototoxicity, TTP (thrombocytopenia)
Which antibiotic can cause serotonin syndrome because of an interaction with MAO, and also causes myelosuppression (anemia, leukopenia)?
Linezolid (Zyvox)
Which antibiotic can cause QT prolongation?
Azithromycin (Zithromax)
Macrolides (azithromycin, clarithromycin, erythromycin)
Which antibiotic is a potent inhibitor of cyp3a4?
Which antibiotic can prolong QT?
Cypa3a4 - Clarithromycin (Biaxin)
Prolong QT - azithromycin
Macrolide family
Which antibiotic has increases the risk for tendonitis – rupture of achilles tendon, neurologic – seizures, confusion, and severe hypoglycemia and increased Morbidity/mortality
Fluoroquinolones
Which antibiotic should be last line because of the multiple FDA warnings?
Fluoroquinolones
Which fluroquinolone is the first fluoroquinolone antibiotic with activity against methicillin-resistantStaphylococcus aureus(MRSA) and, unlike the other fluoroquinolones, is not associated with QT prolongation or photosensitivity.
Delafloxacin (Baxdela)
Dela”firstfluroquinolone”oxacin
Which antibiotic causes inhibition of bone growth (2nd/3rd trimester through the age of 8), hepatotoxicity, tooth discoloration and enamel hypoplasia
Tetracyclines
(doxycycline)
Which antibiotic works on acne but has a host of negative side effects?
Doxycycline (Vibramycin)
Tetracycline family
Which antibiotic interferes with DNA synthesis….Not enough folic acid
Trimethoprim/Sulfamethoxazole (Bactrim, Septra)
Aminoglycoside
Which med is used for patients with implanted device that is growing biofilms over it
Rifampin and Rifabutin
Also a potent inducer of the CYP 450 system with significant interactions
Rare hepatotoxicity, **orange-red body fluids
*Mostly for TB and prosthetics
Which antibiotics are safest for use in pregnancy?
Penicillins, Cephalosporins, Erythromycin
Which antibiotic in pregnant women is associated with acute fatty necrosis of the liver, pancreatitis, and possible renal injury?
Tetracycline
Which antibiotics should you avoid in pregnancy?
Metronidazole, ticarcillin, rifampin, trimethoprim, fluoroquinolones, and tetracyclines
What should you think when you hear antifungals?
anti-fungal – think drug interactions
What are some characteristics of type 1 DM?
Before Age 30 (Child)
Abrupt Onset
Requires exogenous insulin to treat
Ketoacidosis prone
Wide fluctuations in BG concentration
Thin body habitus
Altered Human Lymphocyte Antigen on the short arm of chromosome 6
Defect causes “insulinitis”
Autoantibodies may be detected at the time of diagnosis but maybe absent years later.
The pathologic hallmark of T1D has long been considered the inflammatory lesion of the pancreatic islets, which is termed insulitis and is characterized by the presence of immune and inflammatory cells within and around the pancreatic islets 6. Insulitis is the manifestation of the autoimmune attack against beta cells.
What are some characteristics of type 2 diabetes?
Adult onset: historically
May require exogenous insulin
Not ketoacidosis prone
Relatively stable BG concentration
Obese body habitus
How do you diagnose DM?
Fasting BS 126mg/dl or greater (usually x 2)
Random BS >200mg/dl
What is HgA1C?
Measure of the percent of Hgb that has been non-enzymatically glycosylated by glucose on the Beta chain
Normal: 4-6%
ADA recommends <7-8.5% depending on the age of the diabetic patient.
Gives an idea of the degree of control of BG levels over the past 3 months.
Assesses the long-range effectiveness of glucose control.
Urinary ketones
Monitor patients at risk of going into diabetic ketoacidosis (Type I DM)
Used by patients if they develop symptoms of cold, flu, vomiting, abdominal pain, polyuria, or on finding an unexpectedly high glucose lev
What does insulin do to electrolytes?
Potassium in
Magnesium in
Phosphorus in
Sodium out
Does insulin facilitate glycogenesis, gluconeogenesis, or glycogenolysis?
Shift intracellular glucose metabolism toward storage (Glycogenesis)
glycogenolysis - the breakdown of glycogen into glucose. gluconeogenesis - the manufacture of glucose from non carbohydrate sources, mostly protein.
When does insulin resistance occur?
Occurs when there is an impaired intracellular insulin signal that results in decreased recruitment of glucose transport proteins to the plasma membrane and subsequent decrease glucose uptake.
Compensatory hyperinsulinemia occurs to overcome this resistance
When does insulin receptor saturation occur?
Insulin receptors are ______ related to plasma concentrations of insulin
Occurs with low circulating concentrations of insulin
Body increases insulin receptors in response to insulin resistance. INVERSELY related to the plasma concentration of insulin.
How much insulin does the body secrete per day?
Normally release about 1 unit of insulin an/hr… per day about 40-50 units
What types of insulin can you give via IV pump?
Any short acting
What are symptoms of hypoglycemia?
Symptoms reflect the compensatory effects of increased epinephrine (body kicks out epi in response to hypoglycemia)(beta blockers hide this and mask hypoglycemia symptoms):
Diaphoresis
Tachycardia
Hypertension
Basically epinephrine’s effects
What is re-feeding syndrome?
When the body up-regulates insulin receptors in response to not eating in a LONG time and then that person smashes several double quarter pounders and a few kit-kat bars and all those new insulin receptors move in ALL the electrolytes and kicks out sodium and that person dies
What defines insulin resistance?
Patients requiring > 100 units/day
Has immunoresistance been eliminated with the switch from animal insulin to human insulin?
YES
Method of insulin injection
Administer 70% of total dose as intermediate or long acting at bedtime (basal insulin)
Type I DM may require intermediate or long acting insulin in the AM as well
Additional doses (30%) based on meals size
Administer a rapid acting prep before each meal or snack (4 doses)
What is inhaled insulin (afreeza) used for?
People VERY frightened of injections
Can you ever use sliding scale alone?
NEVER NEVER use sliding scales alone
What are some risks of hyperglycemia?
Microangiopathy
Impaired leukocyte function
Cerebral edema
Impaired wound healing
Postoperative sepsis
Hyponatremia
Wha are perioperative goals for blood sugar?
Optimal BG levels 110-180mg/dl
<150mg/dl for total joints
Glucose infusion if BG decreases to <80mg/dl
Loose control: ¼ to ½ the dose of intermediate or long acting insulin – the last dose prior to procedure
If the procedure is short, may give regular daily dose
Tight control: infusion
How do you treat someone with an insulin pump?
Prior to surgery clear liquids with or without sugar
Maintain basal infusion rate
Turn off preprandial boluses
Measure BG every hour
Know the typical bolus for the patient to decrease BG 50mg/dl
Which class of oral hypoglycemics has the highest risk of hypoglycemia?
Sulfonylureas (Ex: Glipizide)
What class of oral hypoglycemics have a high rate of failure?
Sulfonylureas
sul”fail”ureas
Is there any cross-sensitivity with sulfonylureas and sulfa drugs?
YES. Not necessarily sulfa antibiotics
True/False The risk of hypoglycemia is worse with sulfonylureas in kidney patients because this class is excreted by the kidneys?
TRUE
Which sulfonylurea is the worst for kidney patients?
Glyburide longest acting and most touchY with kidneys GFR LESS THAN 50 CONTRAINDICATED.
Which sulfonylurea is the least safe?
Glyburide (DiaBeta®, Micronase®):
Gly”bad”uride
Which sulfonylurea is the longest lasting and can cause severe hyponatremia?
Chlorpropamide (Diabinese®)
Ch”longlasting”rpropamide
Which med reduces Absorption of carbs by inhibiting the breakdown of carbs?
Alpha- Glucosidase Inhibitors
Acarbose (Precose®)
Miglitol (Glyset®)
Which med should you NEVER give while fasting because it secretes insulin?
Meglitinides
megliti”nevergivewhilefasting”idines
Repaglinide (Prandin ®)
Nateglinide (Starlix®)
Metformin has a black box warning for which of the following side effects?
Lactic acidosis
What is the #1 med for DM II
Metformin
Why is metformin great?
Decrease BG concentrations with only a very low risk of hypoglycemia.
Have a positive effect on lipid concentrations.
Lead to mild weight reduction in obese pts.
NO weight gain
Risk of hypoglycemia FAR lower
Dec hepatic glucose production
Reduces glucose absorption from the intestine
Increases insulin sensitivity
Discontinue metformin _____ days before elective surgery and ____ before contrast dye.
48 hours before both…also hold 48 hours post-dye
What are the parameters for metformin contraindication?
Contraindicated SCr >1.5 (males), 1.4 (females) (old recommendations)
STOP IF Contraindicated eGFR <30 ml/min,
do not initiate for new patients or re-evaluate patients with eGFR <45 ml/min (new recommendations)
Age > 80 years old
Hepatic impairment
CHF
What the heck do DPP (Dipeptidyl peptidase)-4 Inhibitors do?
Dipeptidyl peptidase-4 (DPP-4) inhibitors block the breakdown of GLP-1 and GIP to increase levels of the active hormones. In clinical trials, DPP-4 inhibitors have a modest impact on glycemic control. They are generally well-tolerated, weight neutral and do not increase the risk of hypoglycemia
Which class delays gastric emptying and is made from guila monsters?
Amylin analog (GLP-1?)
Amylin analoguila-monster
Although sulfonylureas are the worst for hypoglycemia, which other class has a black-box warning for hypoglycemia and causes severe gastroparesis?
Amylin analog (GLP-1)?
Which class increases urinary excretion of glucose and sodium?
SGLT2 Inhibitor
SG”Let it go” T2 inhibitors
Canagliflozin (Invokana)
Dapagliflozin (Farxiga)
Empagliflozin (Jardiance)
Which class of med increases the risk of increased risk of perioperative euglycemic ketoacidosis as well as
amputations (primarily toe) AND can cause hypotension??
SGLT2 Inhibitor
SGLow ph, low pressure, low toe” T2 inhibitors
Canagliflozin (Invokana)
Dapagliflozin (Farxiga)
Empagliflozin (Jardiance)
Which two meds are contraindicated with a GFR under 30?
metformin and SGLT2 inhibitors
Because of increased risk of ketoacidosis, how long should SGLT2 inhibitors be held prior to surgery?
Canagliflozin, dapagliflozin, and empagliflozin should be discontinued 3 days before scheduled surgery.
“C,D,Empa, THREE”
Ertugliflozin should be stopped at least 4 days before scheduled surgery.
“Ertu for EFFORT”
What two meds can delay the onset of type 1 diabetes?
Teplizumab-mzwv (Tzield) and verapamil
Which thyroid med is a combo of T3 AND T4?
Armour Thyroid (combo T3&T4)
Which thyroid med is just T4, and is the most commonly prescribed med for hypothyroidism?
Levothyroxine (T4) (Synthroid®)
Which thyroid med is just T3 and has increased cardiovascular side-effects?
Liothyronine (T3) (Cytomel®)
Here’s a laundry list of anesthetic considerations for patients with hypothyroidism
Basically, your body and metabolism are SLOW so meds effect you more…
Increased sensitivity to depressant drugs
Including inhaled anesthetics.
Hypodynamic cardiovascular system.
Decreased CO due to decreased HR and SV.
Slowed metabolism of drugs, particularly opioids.
Unresponsive baroreceptor reflexes.
Decreased intravascular fluid volume.
Impaired ventilatory response to low PaO2 and/or increased PaCO2…
Delayed gastric emptying.
Hyponatremic.
Hypothermic.
Anemic.
Hypoglycemic.
Primary adrenal insufficiency.
Which antithyroid meds are useful in treating hyperthyroidism (including thyroid storm) before elective thyroidectomy?
Propylthiouracil (PTU)
Methimazole (Tapazole®)
What is the oldest effective treatment for hyperthyoid?
Iodines:
Lugol’s Solution
Saturated KI solution
Here’s the treatment for thyroid storm
I.V. infusion of cold crystalloid solns.
Sodium iodide I.V.:
Reduce the release of active hormones from the thyroid gland.
Cortisol I.V.:
Treat acute primary adrenal insufficiency from increased metabolism and use of corticosteroids.
Propranolol I.V.:
Alleviate the cardiovascular effects of thyroid hormones.
Propylthiouracil P.O.:
Reduce the synthesis of new thyroid hormone.
Avoid ASA/NASID for elevated temperature because it may displace thyroxine from carrier proteins.
Which oral hypoglycemic may exacerbate hypotension?
Canagliflozin (Invokana)
Insulin produces all of the following effects except…
Stimulate glycogenolysis
Which of the following is not significantly shifted intracellularly when insulin binds to its cellular receptors?
Sodium
SGLT2 inhibitors may increase the risk of perioperative euglycemic ketoacidosis. The FDA recommends stopping this class of medications how many days prior to a procedure to reduce this risk?
3 days
Which insulin is the most rapid acting?
Humalog (Lispro)
A patient uses 20 units of Lantus (Glargine) at bedtime and has surgery scheduled in the morning. How much Lantus should be administered the night before the procedure?
10 units
Reduces absorption of carbs by inhibiting the breakdown of carbs?
Which med should you NEVER give while fasting because it secretes insulin?
Alpha- Glucosidase Inhibitors (Acarbose (Precose®)
Miglitol (Glyset®)
Meglitinides (megliti”nevergivewhilefasting”idines)
Amylin analog (GLP-1?) (Amylin analoguila-monster)
What percent of inhaled meds actually get to the lungs?
12%
What order do you give inhaled meds?
Give bronchodilators, then anything with a steroid second. Open up lung field to increase surface area
What muscarinic receptors act where?
M3 – primary in lungs.
M2 in heart.
M4 CNS
Is glycopyrrolate used for acute management?
NO
Probably for long-term COPD
Which agent is most effective in treating bronchospasm due to beta antagonists?
Ipratropium (atrovent)
More effective than beta-agonists in chronic bronchitis or emphysema
Duoneb/Combivent ®- in combo with albuterol
What are the two main side-effects of inhaled anticholinergics?
Narrow angle glaucoma
Urinary retention
Are beta-2 agonists metabolized by COMT and MAO?
Non-catecholamine structure makes them resistant to COMT. MAO only
What are the uses for inhaled beta 2 agonists?
Preferred treatment for acute episodes of asthma.
Prevention of exercise-induced asthma.
Improve airflow and exercise tolerance in patients with COPD.
Tocolytic to stop premature uterine contractions.
Treatment of hyperkalemia
What is the preferred treatment for acute episodes of asthma?
Inhaled beta 2 agonists
Which med is inhaled epinephrine?
Primatene Mist
Isoproterenol
Non-selective sympathomimetic
Act at Beta1 and Beta2 receptors.
Highly pro-arrhythmic.
What is the preferred Beta2 agonist for acute bronchospasm?
Albuterol
Why were short acting beta agonists made? Meds like levoalbuterol and metaproterenol?
Made because of “less cardiostimulatory effects”…for people with a-fib, etc…
What is terbutaline and ritodrine?
Tocolytic- reduces contractions to postpone labor for hours to days – used in O.B
What are beta-2 agonists also used for?
Treating hyperkalemia….they cause hypokalemia
They also CAUSE hyperglycemia
Which class of medication is unsafe to use as monotherapy due to an increased risk of asthma related death?
Long acting beta agonist (LABA)
Which class of med is used in prophylactic treatment of bronchial asthma and has
no role in the treatment of established (acute) bronchoconstriction?
Membrane Stabilizers like cromolyn sodium
What are methylxanthines?
Theophylline/Aminophylline
Caffeine
Theobromine
They are non-selective Phosphodiesterase Inhibitors and inhibit all fractions of PDE isoenzymes
Stimulate the CNS.
Inc BP
Increase myocardial contractility and heart rate
PDE3
Relax smooth muscle (airways). PDE4
Which methylxhanthine is used for treatment of bronchospasm due to acute exacerbation of asthma and has various toxicity levels associated with v-tach and seizures?
Theophylline
15-25 mcg/ml: GI upset, N/V, tremor
25-35: Tachycardia, PVCs
> 35: VTach, seizures
Caffeine
Adenosine releases Gaba leading to drowsiness. Caffeine blocks adenosine leading to less GABA.
Vasoconstriction from adenosine A1 effects…helps headaches by constricting..
Histamine receptors
4 types, but drugs typically target H1 and H2
Benadryl plus Pepcid to combat the H1 AND H2 receptors..have to give both
H-1 Receptors
Evoke smooth muscle contraction in the respiratory and G.I. tracts.
Cause pruritus and sneezing by sensory nerve stimulation.
Causes nitric oxide mediated vasodilitation.
Slow the heart rate by decreasing A-V nodal conduction.
Mediate epicardial coronary vasoconstriction.
H-2 Receptors
Activates adenyl cyclase and increases intracellular cAMP.
Activates proton pump of gastric parietal cells to secrete hydrogen ion.
Increase myocardial contractility and heart rate.
Vasodilating effects on coronary vasculature opposes the vasoconstricting effects of H1 receptors.
With H1 receptors increase capillary permeability and vasodilitation.
H-2 Receptors
Activates adenyl cyclase and increases intracellular cAMP.
Activates proton pump of gastric parietal cells to secrete hydrogen ion.
Increase myocardial contractility and heart rate.
Vasodilating effects on coronary vasculature opposes the vasoconstricting effects of H1 receptors.
With H1 receptors increase capillary permeability and vasodilitation.
Which histamine receptors do you need to completely block to block the vasodilatory effects?
Need H1 and H2 blockers
What is the triple response (wheel and flare)?
Edema due to increased permeability.
Dilated arteries around the edema (Flare).
Due to histamine stimulating nerve endings.
Pruritus due to histamine in the superficial layers of the skin.
H1 vs H2 on airway
H1 constricts, H2 relaxes
What is the difference between the two generations of H1 receptor antagonists?
The first generation is more sedating and have anticholinergic effects and have more QT prolongation
What are H1 clinical uses?
prevent allergic rhinitis, antipruritic, sedative, antiemetic, some protection against bronchospasm
What are H1 clinical uses?
prevent allergic rhinitis, antipruritic, sedative, antiemetic, some protection against bronchospasm
Does having Benadryl on board make for a difficult reversal with naloxone?
YEP
What is Dimenhydrinate (Dramamine®) used for?
Used to treat motion sickness and PONV.
What are some 2nd generation antihistamines?
Zyrtec/Xyzal = Cetirizine/Levocetirizine
Claritin= Loratidine
Allegra: Fexofenadine
What is the closest thing we have to cortisol?
Hydrocortisone
Tell me about aldosterone..
Secreted secondary to inc K, dec Na, dec BP/fluid volume
Renin -> AG1 -> AG2 -> Aldosterone
Effects:
K excretion
Na retention
Increase water retention, increase blood volume
renin released from the kidney, angiotensinogen released from the liver…renin acts on angiotensinogen to make angiotensin 1…ACE acts on angiotensin 1 to make angiotensin 2…angiotensin 2 acts on the adrenal gland to make aldosterone..aldosterone acts on the kidney to absorb NA and water! yay! go fuck yaself!
What is another name for primary adrenal insufficiency, and what is happening with it?
Addison’s Disease
Adrenals do not secrete cortisol or aldosterone
Replacement therapy must include glucocorticoid and mineralocorticoid (must include both)
What is secondary adrenal insufficiency?
Due to chronic steroid use and suppression of the H-P-A axis.
Aldosterone secretion maintained
Replacement usually requires only glucocorticoid (anti-inflammatory)
Glucocorticoids have a _____ effect while mineralocorticoids have a _____ effect
glucocorticoids are anti-inflammatory
mineralocorticoids reabsorb NA for K excretion
Which steroids are naturally occurring?
Cortisol (hydrocortisone)
Cortisone
Corticosterone
Desoxycorticosterone
Aldosterone
Which steroids are synthetic?
Glucocorticoids:
Prednisolone
Prednisone
Methylprednisolone
Betamethasone
Dexamethasone
Triamcinolone
Mineralocorticoids:
fludrocortisone
What is the antiinflammatory:NA absorbent (glucocorticoid:mineralcorticoid) relationship for cortisol?
Cortisol (hydrocortisone) has 1:1 effect
Anti-inflammatory alone AND mixed
anti-inflammatory only:
dexamethasone, betamethasone, triamcinolone
Both:
cortisol, cortisone, prednisolone, prednisone, methylprednisolone
fludrocortisone does both but WAY more sodium retaining
Which of the following has both anti-inflammatory and mineralocorticoid effects?
Methylprednisolone
Also, cortisol, hydrocortisone, prednisone, prednisolone, methylprednisone
Which corticosteroid has WAYYYYY more NA retaining (mineralocorticoid) properties than anti-inflammatory (glucocorticoid)?
FLUDRACORTISONE
10:125
Do we need to taper steroids?
YES we need to stop steroids SLOWLY or they will go into an adrenal crisis
Which is an absolute contraindication for corticosteroid use?
None of the above!!
Answers:
A.
Hyperglycemia
B.
Edema
C.
Infection
CorrectD.
None of the above
What are the electrolyte changes with corticosteroids?
Hint: this also happens with thiazides and loop diuretics
Hypokalemic Metabolic Alkalosis:
Mineralocorticoid effect of cortisol on distal renal tubules leading to enhanced absorption of Na+ and loss of K+
What do corticosteroids do regarding blood sugar?
Promote hepatic gluconeogenesis
Resultant hyperglycemia may require diet, insulin, or both to manage
What does taking too may steroids do to the body?
CUSHINGS DISEASE YUCK
Redistribution of body fat:
Deposition on back (buffalo hump), supraclavicular, and face (moon facies)
Loss of fat from the extremities
What can happen if you give even small doses of glucocorticoids to children?
Arrest of growth can result from the administration of relatively small doses of glucocorticoids to children
Why do surgeons care about giving steroids intraoperatively?
Masking infection or further complicating surgery intended to treat infection
Altering glucose control in diabetics
Aseptic necrosis of the femoral head
Failure of bone fusion
HPA suppression
Therapies unlikely to suppress H-P-A Axis:
Prednisone 5mg/day or less or 10 mg QOD
Long term every other day dosing associated with less suppression
Glucocorticoids, any dose < 3 weeks does not clinically suppress the H-P-A Axis
Prednisone or Dexamethasone (even physiologic doses) given as a single daily dose at bedtime is associated more commonly with H-P-A Axis suppression
Bedtime dosing more commonly associated
Therapies assumed to suppress H-P-A Axis (absolutely yes it will):
Prednisone 20mg/day (or equivalent) for > 3 weeks within the previous year
Patient with clinical signs of Cushing Syndrome from any steroid dose
No need to test the H-P-A Axis in these patients, just supplement with stress dose steroids
Therapies that may or may not suppress H-P-A Axis:
> 5mg/day but < 20mg/day of prednisone (or equivalent) for > 3 weeks the previous year
May have suppression of the H-P-A function depending on:
Dose
Duration
Individual patient
*After cessation of steroid therapy, recovery of the H-P-A function can take 12 months or longer
H-P function returns to normal before adrenal function
Options:
Test for responsiveness of the adrenals if time permits
Cosyntropin (ACTH) stimulation test
Give stress doses of glucocorticoids prophylactically (assume suppressed)
Do burns or sepsis increase the need for steroids?
YES they surely do
Signs and Symptoms of Acute Adrenal Crisis
Hypotension unresponsive to vasopressors
Hypoglycemia
Hyponatremia
Hypovolemia
Hyperdynamic circulation
Hyperkalemia
Metabolic acidosis
Decreased level of consciousness
