Anaesthesiology - Pharmacology Flashcards

1
Q

General Anesthesia

  • Define induction agent
  • Examples
  • Length of action
A

Induction agent: A drug which induces loss of consciousness in one arm-brain circulation time when given at an appropriate dose

Examples: **Benzodiazepines, Etomidate, Propofol, Ketamine **

Length of action of an IV bolus: 3-5 mins effect due to drug redistribution, actual elimination half-life is several hours
Ketamin: 5-10 mins effect, onset time 30s

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2
Q

General Anesthesia
- Define Maintenance agent
- Examples

A
  • Drug used to maintain anesthesia until end of procedure

Examples:
- Volatile anesthetic agents (inhaled halogenated ether compounds): Sevoflurane, desflurane, isoflurane
- Nitrous oxide (inhalation)
- IV injection/ infusion of any induction agents

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3
Q

General Anesthesia
- List general side effects

A
  • Hypoxia
  • Hypotension
  • Sedation
  • Confusion and agitation
  • Nausea and vomiting
  • Headache
  • Shivering
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4
Q

Barbituates
- Mechanism
- PK
- Effects
- Uses

A

Mechanism
- Potentiate effect of GABA at GABAA inhibitory receptor

Pharmacokinetics
- Rapid brain uptake, rapid redistribution, hepatic elimination
- Slow metabolism & prolonged elimination

Effects
- CVS - ↓MAP, ↑HR, myocardial depression
- Respiratory - depression ventilator centre, retain some airway reflexes
- CNS - ↓CMRO2, CBF, ICP, anti-convulsant

Uses
- Obstetrics, RSI, epilepsy/ seizures, neurosurgical emergency

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5
Q

Etomidate
- Mechanism
- PK
- Effects
- Uses

A

Mechanism
- Potentiate effect of GABA at GABAA receptor

Pharmacokinetics
- Rapid onset of action & redistribution. Hydrolysed by plasma esterases & liver

Effects
- CVS - cardiovascular stability, no effect on contractility, SVR, HR
- Respiratory - minimal effect on respiration
- CNS - ↓CMRO2, CBF, ICP
- Other - inhibits 11-β hydroxylase → adrenocortical suppression

Uses
- Cardiac patients
- Haemodynamically unstable patients

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6
Q

Propofol
- Mechanism
- PK
- Effects
- Uses

A

Mechanism
- Potentiate effect of GABA at inhibitory GABAA receptor

Pharmacokinetics
- Rapid onset, rapid redistribution, metabolised in liver, high clearance

Effects
- CVS - ↓SVR, cardiac contractility, preload
- Respiratory - ↓resp depression, obtunds laryngeal reflexes
- CNS - ↓CMRO2, CBF, ICP, burst suppression
- Others - fast clear headed wake-up, anti-emetic, propofol infusion syndrome

Uses
- Most suitable for infusion of induction agents
- Used with ultra-short-acting opioid remifentanil- synergistic effect

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7
Q

Ketamine
- Mechanism
- PK
- Effects
- Uses

A

Mechanism
- Inhibits excitatory NT glutamate at NMDA receptors
Dissociative anaesthesia rather than hypnosis

Pharmacokinetics
- Rapid onset, slower redistribution, hepatic metabolism to norketamine

Effects
- CVS - ↑HR, SVR, CO by SNS activation
- Respiratory - little effect on rate, bronchodilator, salivation, reflexes preserved
- CNS - ↑CBF, ICP, CMRO2, hallucinations, amnesic
- Others - analgesic

Uses
- Shocked patients
- As analgesic

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8
Q

Volatile anesthetic agents
- Mechanism
- Effects
- Examples

A
  • Effect: Mainstay of anaesthetic maintenance
  • Examples: Sevoflurane, desflurane, isoflurane
    Halogenated ether compounds- comes in liquid form
  • Mechanism:
    A device called a vaporiser adds a known concentration of volatile agent to a gas mixture (usually N2O, O2 or air/O2) which patient inhales via a breathing circuit
    Concentration can be adjusted to keep appropriate concentration of volatile in the lungs
    When volatile is stopped, as the patient exhales it is eliminated. When the alveolar concentration drops to a critical level, patient wakes up
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9
Q

Nitrous Oxide
- Mechanism
- Effects
- Advantages and disadvantages

A

Nitrous oxide (inhalation)
- Mechanism: Given with O2 or air in a gas mixture to inhale
- Effect: Weak anaesthetic, need to breathe 104% to achieve anaesthesia

Advantages
* Good analgesia
* Reduces MAC

Disadvantages
* PONV
* Diffusion into gas filled spaces
* Effects on bone marrow
* Environmental issues

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10
Q

Induction agents
- Mechanism
- Disadvantages
- S/E

A

All induction agents are suitable to maintain anaesthesia if given as infusion or regular boluses

Disadvantages with maintenance with induction agent:
- Accumulation on repeated dosing
- Very prolonged duration of action
- Difficult dose timing

Side effects
* Etomidate: adrenocortical suppression
* High doses of propofol: propofol infusion syndrome

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11
Q

Explain why GA agents cause Hypoxia

A

Hypoventilation
* Airway obstruction- tongue, oedema, laryngospasm
* Respiratory depression
* Residual neuromuscular blockade
* Poor analgesia

VQ mismatch
* Reduced CO & FRC

Shunt
* Small airways closure, lung perfused but not ventilated

Diffusion hypoxia
- N2O more soluble than O2, when N2O stopped, it diffuses into alveoli from blood faster than N2 can diffuse in opposite direction. This concentrates N2O compared to other gases in alveoli and decreases FiO2.

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12
Q

Explain why GA agents cause sedation, confusion and agitation

A

Multiple causes from GA

  • residual effect of anaesthetic/analgesic drugs
  • hypoxia
  • hypotension
  • hypoglycaemia
  • hypothermia
  • electrolyte disturbance
  • intracranial pathology
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13
Q

Local Anesthetics
- MoA
- Examples
- Dose calculations

A

MoA: Sodium channel blocker
- Local anaesthetics enter the nerve in the unionised lipid-soluble free base form
- Once inside the nerve, it ionises and the ionised form enters and blocks sodium channels.
- Once enough sodium channels are blocked, depolarisation is prevented and action potentials cannot be generated, leading to nerve blockade

Examples:
- Bupivacaine, Levo-bupivacaine, Ropivacaine
- Lignocaine, Lidocaine
- Cacaine
- EMLA: Lignocaine + Prilocaine
- Additive: Adrenaline (for slower LA absorption)

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14
Q

Anxiolytics
- MoA
- Examples
- Effects
- Uses
- S/E
- Antagonist

A

MoA: enhancing GABAA inhibitory neurotransmission, increase GABA affinity to GABA-receptros, increase Cl- influx, increase hyperpolarization

Examples: BDZs
- Short-acting: Triazolam, Midazolam
- Intermediate: Temazepam, Alprazolam, Lorazepam
- Long-acting: Diazepam, Clonazepam, Flurazepam
Examples: Barbituates
- Ultra-short acting: Thiopental/ Thiopentone
- Short-acting: Pentobarbital
- Long-acting: Phenobarbital

Effects: Anxiolytic, Hypnotic, Sedation/ muscle relaxation, Anti-convulsion (note: no analgesic or antipsychotic effect)

Uses:
- Sedation, anxiolysis, GA induction, Anti-convulsion

S/E:
- Drowsiness and confusion
- Poor motor control and ataxia
- Anterograde amnesia
- Respiratory depressionm, coma
- Barbituates: Severe withdrawal symptoms, CYP450 induction, Addiction

Antagonist: Flumazenil (competitive BDZ antagonist)

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15
Q

Antiemetics
- Examples
- MoA/ pathways

A
  • Block neurotrasmission (5HT3, D2, H1, ACh, NK1) into chemoreceptor trigger zone (area postrema at floor of 4th ventricle outside of blood brain barrier)
  • Block output to vomiting center and nucleus tractus solitarius (NTS)

Examples:
First line:
- Anti-serotonin: Ondansetron
- Steroids: Dexamethasone

Second line:
- Anti-cholinergics: Hyoscine
- Anti-histamines: Cyclizine
- Anti-dopaminergics: Metoclopramide, prochlorperazine

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16
Q

Post-operative nausea and vomiting (PONV)

  • List patient factors, surgical factors and anesthetic factors
A

Patient factors
- Female, young, non-smoker, history of PONV, travel sickness

Surgical factors
- Surgery type: ENT, eye, abdominal, gynaecological
- Surgical technique: laparoscopic
- Surgical complication: swallowed blood

Anaesthetic factors
- Pharmacological: opioid, N2O, volatile agent
- Others: dehydration, poorly controlled pain, anxiety
- Failure to give prophylaxis in high-risk patient

17
Q

Analgesics
- Classes and Examples
- Antagonist

A

Analgesic and anti-inflammatory drugs:
Paracetamol
NSAIDs:
* Salicylates: Aspirin, Dilflunisal
* Propionic acids: Naproxen, Ibuprofen
* Acetic acids: Indomethacin, Sulindac
* Oxicams: Prioxicam
* Fenamates: Meclofenamic acid
* Selective COX-2 inhibitors: Celecoxib, Etoricoxib, Rofecoxib

Narcotic analgesics/ Opioids
- Morphine derivatives: Morphine, Codeine, Heroin
- Phenylpiperidine: Pethidine, Fentanyl, Sufentanil, Alfentanil, Remifentanil
- Methadone
- Propoxyphene
- Tramadol
Antagonist: Naloxone

18
Q

Paracetamol
- MoA
- Effects
- S/E

A

MoA: inhibition of central prostaglandn synthesis, possibly multi-receptor action - COX (but not COX1 or COX2), serotonergic, endocannabinoid

Effects: Analgesics, Antipyretic, NOT anti-inflammatory

S/E: Skin rash, minor allergy, Asthma for GSH-deficient), NAPQI hepatotoxic intermediate in overdose

19
Q

Opioid
- MoA
- S/E

A

Opioids MoA: Bind to mu-receptors in CNS (mu-1R block for supraspinal and peripheral analgesia; mu-2R block for spinal analgesia)
(Tramadol blocks serotonin and catecholamine reuptake)

S/E:
Acute S/E: Sedation, N/V, Respiratory depression, Euphoria (esp. Pethidine, morphine), Miosis, hypotension and bradycardia

Prolonged use S/E: Constipation, tolerance, dependance, arrhythmia (esp. Propoxyphene), Convulsion/ Seizure (esp. Pethidine/ kidney failure), hormonal effects: ACTH, Prolactin suppression

  • Respiratory depression
  • Euphoria
  • Sedation
  • Nausea & vomiting
  • Bradycardia & hypotension
  • Constipation
  • Histamine release
  • Hormonal effects- suppression of ACTH, prolactin
  • Tolerance & dependence
20
Q

NSAIDs
- MoA
- Effects
- S/E

A

MoA: Inhibit COX 1 or 2, decrease prostaglandin and TXA2 production

Effects: Analgesic, anti-pyretic, anti-inflammatory

S/E:
- GI bleeding, gastric ulceration (decrease protective PG production)
- Bleeding: Block Thromboxane A2 synethesis for aggregation, adhesion and vasoconstriction
- GI disturbances: dyspepsia, Diarrhoea/ constipation, N/V
- Asthma induction: shunt arachidonic acids into leukotrienes for bronchospasm
- Analgesic- associated nephropathy: Decrease renal angiotensins, block renal blood flow, cause interstitial nephritis
- Ischemic heart disease: Block PGI2 production for vasodilation and anti-thrombosis + increase TXA2 production for vasoconstriction and pro-thrombosis
- Skin rash/ urticaria/ photosensitivity

21
Q

Neuromuscular blockers
- Examples
- Classes
- MoA

A

Depolarising NMB
- Succinylcholine (aka Suxamethonium), Decamethonium
- MoA: Nicotinic AChR agonist, sustained membrane depolarization, closure of h-gate, inactivate V-gated cation channels

Non-depolarizing NMBs
- Short acting: Mivacurium
- Intermediate: Atracurium, Cis-atracurium
- Steroidal: Vecuronium, Rocuronium
- Long-acting: Pancuronium, Tubocurarine
- MoA: Nicotinic AChR antagonist, competitive blockage of ACh-gated cation channels, sustained ACh-gated and V-gated channel close

22
Q

Neuromuscular blockers
- S/E
- Route of elimination

A

Depolarising NMB:
- Muscle pain by fasciculation
- Malignant hyperpyrexia
- Raised intra-ocular pressure and intra-gastric pressure
- Hyperkalemia: Arrhythmia
- Bradycardia (reduce with Atropine)
- Allergy/type 1 hypersensitivity and anaphylaxis to Quaternary Ammonium Compounds (QACs)
- Elimination by Pseudocholinesterases (PChE) at NMJ

Non-depolarising NMB:
- Bronchospasm (histamine release)
- Hypotension (Sympathetic block)
- Allergy to QACs
- Elimination: Hoffman elimination for atracurium; hepatic/ renal elimination for others