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Anesthesia Pharm > Antibiotics, Steroids & Antiemetics > Flashcards

Antibiotics, Steroids & Antiemetics Flashcards

1
Q

Risk Factors for Surgical Site Infections

A

Diabetes

Smoking

Colonization with microorganisms

Hypothermia

Skin antisepsis

Pre-op shaving

inadequate sterilization of instruments

surgical technique

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2
Q

When are periop antibiotics administered? What is the goal?

A

­ATB are administered 1 hour before incision

­Goal is for ATBs to be present at the skin during incision

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3
Q

______ ­can be pushed IV and quickly distribute to the skin.

A

Cephalosporins

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4
Q

_____ require longer infusion times (60 minutes)

A

Vancomycin and metronidazole

Should initiate infusion administration preoperatively

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5
Q

Redosing of the antibiotics depends on ____

A

­the ATB’s half-life, the patient’s renal function and blood loss during the case

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6
Q

Half life of ­ampicillin

A

2 hours

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7
Q

Half life of ­cefazolin

A

4 hours

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8
Q

Concerning if creatinine clearance is ___

A

< ­60 ml/min

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9
Q

Gentamycin and vancomycin have ____.

A

­a narrower therapeutic index than cephalosporins

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10
Q

Redose antibiotic if estimated blood loss is ___.

A

­more than 1.5 L

­Vancomycin: half-dose

­Other cephalosporins: full dose

­Postop redosing should be limited to less than 24 hours

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11
Q

Clean skin wounds are at increase risk for ____.

A

staphylococcus aureus and coagulase negative staphylococci infections

thus, cefazolin is recommended, and if a severe beta-lactum allergy (hives, anaphylaxis), clindamycin or vancomycin

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12
Q

Contaminated skin wounds are at increase risk for ____.

A

staphylococcus aureus and streptococci infections

thus, cefazolin and metronidazole is recommended, and if a severe beta-lactum allergy (hives, anaphylaxis) clindamycin

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13
Q

Contaminated oral wounds are at increase risk for ___.

A

non-bacteroides fragilis, peptostreptococcus, and prevotella infections

thus ampicillin/sulbactam is recommended, and if a severe beta-lactum allergy (hives, anaphylaxis) clindamycin

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14
Q

Biliary/GI wounds are at increase risk for ____.

A

staphylococcus aureus and anaerobic, gram negative rod infections

thus, cefazolin and metronidazole is recommended, and if a severe beta-lactum allergy (hives, anaphylaxis) clindamycin and an aminoglycoside or fluoroquinolone

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15
Q

Patients Presenting for procedures already on ATB

A

Consider how long your patient has been on antibiotics, their last dose, when their next dose is due, and whether their current ATB regiment offers appropriate coverage for the scheduled procedure.

Do not hesitate to reach to collaborate with your department’s pharmacists for a consult.

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16
Q

Cefazolin

A

First generation cephalosporin

Wide therapeutic window

Inhibits bacterial cell wall synthesis

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17
Q

Dosing for Cefazolin

A

­2g for most healthy adults

­3 g for patients greater than 120 kg

­25 mg/kg for patients less than 40 kg

Inject direct IV over 3 to 5 minutes

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18
Q

Penicillin allergy

A

­10% of patients report a pcn allergy

­90% of these patients are able to tolerate pcns

­A 0.1% reaction rate is reported among pts with pcn allergy history (without pcn skin test) receiving cephalosportins

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19
Q

Vancomycin

A

Broad spectrum antibiotic

MOA: Inhibits cell wall synthesis

Often administered to patients with MRSA

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20
Q

Dosing for Vancomycin

A

1g administered over an hour, completed prior to incision

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21
Q

Examples of Beta-Lactams

Risks?

A

Penicillin, cephalosporins, ampicillin

Risk for Allergic reaction

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22
Q

Example of Aminoglycosides

Risks?

A

Gentamycin, streptomycin

Risk for ototoxicity, nephrotoxicity & skeletal muscle weakness

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23
Q

Example of Tetracyclines

Risks?

A

Doxycycline

Risk for Hepatoxicity & Nephrotoxicity

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24
Q

Example of Fluoroquinolones

Risks?

A

Ciprofloxacin, Levofloxacin

Risk for GI intolerance

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25
Q

Example of Macrolides

Risks?

A

Erythromycin

Risk for P450 inhibition

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26
Q

Risk for Clindamycin

A

Skeletal muscle weakness

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27
Q

Risks for Vancomycin

A

Hypotension with rapid infusion

Red man syndrome

Steven Johnson Syndrome

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28
Q

Risks for Metronidazole

A

Peripheral neuropathy

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29
Q

Effect of glucocorticoids on lungs and CNS

A

Lung maturation

CNS: anxiety, memory

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30
Q

Effect of glucocorticoids on heart and adipose tissue

A

CV: Hypertension

Adipose Tissue: obesity, lipolysis

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31
Q

Effect of glucocorticoids on skeletal muscle and bone

A

Skeletal muscle: myopathy

Bone: Osteoporosis

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32
Q

Effect of glucocorticoids on liver and immune cells

A

liver: lipid and glucose homeostasis

Immune cells: antiinflammatory & immunomodulation

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33
Q

Chronic glucocorticoid therapy can ____.

A

suppress the hypothalamic-pituitary-adrenal (HPA) axis and, during times of stress such as surgery, the adrenal glands may not respond appropriately.

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34
Q

The use of stress doses of glucocorticoids has become __

A

a common perioperative practice for patients on glucocorticoid therapy, based upon early case reports of intraoperative adrenal crisis after abrupt withdrawal of glucocorticoids

However, several studies suggest that supplemental exogenous stress glucocorticoids may not be needed to meet the demands of perioperative stress

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35
Q

Adverse effects of chronic glucocorticoid therapy

A

● HPA axis suppression

●Impaired wound healing

●Increased friability of skin, superficial blood vessels, and other tissues (eg, mild pressure may cause hematoma or skin ulceration, removing adhesive tape may tear the skin, and sutures may tear the gut wall)

●Increased risk of fracture, infections, gastrointestinal hemorrhage, or ulcer

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36
Q

What are some acute side effects of perioperative glucocorticoids?

A

●Hyperglycemia

●Hypertension

●Fluid retention

●Increased risk of infection

For these reasons, it is important to avoid givng them unless absolutely necessary.

37
Q

The current approach is to determine perioperative glucocorticoid coverage based upon ___

A

1) the patient’s history of glucocorticoid intake
2) the type and duration of surgery planned

38
Q

Patients who should be assumed to have functional suppression of hypothalamic-pituitary-adrenal (HPA) function include ____.

A

Any patient who is currently taking more than 20 mg/day of prednisone or its equivalent (eg, 16 mg/day of methylprednisolone, 2 mg/day of dexamethasone, or 80 mg/day of hydrocortisone) for more than three weeks.

39
Q

Steroid consideration for minor procedures or surgery under local anesthesia

A

(eg, inguinal hernia repair), take usual morning steroid dose. No extra supplementation is necessary.

40
Q

Steroid reccomendations for moderate surgical stress

A

(eg, lower extremity revascularization, total joint replacement)

take usual morning steroid dose. Give 50 mg hydrocortisone intravenously just before the procedure and 25 mg of hydrocortisone every eight hours for 24 hours. Resume usual dose thereafter.

41
Q

Steroid recommendations for major surgical stress

A

(eg, esophagogastrectomy, total proctocolectomy, open heart surgery)

take usual morning steroid dose. Give 100 mg of intravenous hydrocortisone before induction of anesthesia and 50 mg every eight hours for 24 hours. Taper dose by half per day to maintenance level.

42
Q

When selecting a drug to use as a perioperative stress dose, it is important to remember ___.

A

that in secondary adrenal insufficiency, the problem is a glucocorticoid deficiency (as opposed to a mineralocorticoid deficiency); therefore, the relative glucocorticoid and mineralocorticoid activity of the chosen drug must be taken into consideration.

43
Q

Class and use of Dexamethasone

A

Synthetic glucocorticoid steroid

Uses include decreasing risk for PONV, edema (e.g. airway, cerebral), postoperative pain

44
Q

Dosing and DOA of Dexamethasone

A

4 – 12 mg IV

Duration of action can be up to 72 hours

45
Q

Side effects of Dexamethasone

A

delayed wound healing, HPA axis suppression, and hyperglycemia

46
Q

Risk score for PONV in adults

A
  1. Female gender
  2. Nonsmoker
  3. History of PONV or motion sickness
  4. Post-operative opioids

When 0, 1, 2, 3, and 4 of the risk factors are present, the corresponding risk for PONV is about 10%, 20%, 40%, 60%, and 80%, respectively.

47
Q

Risk score for PONV in pediatrics

A
  1. Surgery greater than 30 minutes
  2. Age greater than 3
  3. Strabismus surgery
  4. History of PONV or motion sickness

When 0, 1, 2, 3, or 4 of the depicted independent predictors are present, the corresponding risk for PONV is approximately 10%, 10%, 30%, 50%, or 70%, respectively.

48
Q

What are some anesthetic risk factors for PONV?

A

Volatile Anesthetics

Duration of anesthesia

Sugammadex (limited research)

49
Q

What five neurotransmitter receptor sites are of primary importance in the vomiting reflex?

A
  1. 5-hydroxytryptamine (HT)-3 – serotonin
  2. D2 – dopamine
  3. H1 – histamine
  4. M1 – muscarinic
  5. Neurokinin 1 (NK1) receptor – substance P

Example: D2 = receptor site and when dopamine (neutransmitter) binds to it that causes nausea/vomiting.

50
Q

Describe the steps of Central stimulation for vomiting

A

vestibular system → central pattern generator (vomiting center) in medulla

51
Q

Describe the steps of peripheral stimulation of vomiting

A

irritation of GI tract, overly full stomach → nucleus tractus solitaries in brainstem → area postrema (chemoreceptor trigger zone) at base of fourth ventricle in medulla → communicates with central pattern generator

52
Q

Drugs or chemicals that can be triggering for nausea include

A

dopamine agonsts, cancer chemotherapy, apomorphine, digoxin

53
Q

Some receptors for dopamine (D2) and serotonin (5-HT3) are found in ___ which contributes to nausea.

A

chemotrigger zone (CTZ) & emetic center (within the medulla)

54
Q

Class & Use of Ondansetron

A

Class: 5-HT3 receptor antagonist

Used for PONV, chemotherapy N/V, carcinoid syndrome

55
Q

Mechanism of Ondansetron

A

Inhibits serotonin both peripherally on vagus nerve terminals and centrally in the medulla’s CRTZ

56
Q

Dosing of Ondansetron

A

4 – 8 mg IV

57
Q

Side Effects of Ondansetron

A

Side effects include headache, prolonged QT interval

58
Q

Class and Use of Promethazine

A

Class: Phenothiazine

Used for PONV and motion sickness

59
Q

Mechanism of Promethazine

A

D2 (CRTZ), H1, Muscarinic Antagonist

60
Q

Dosing of Promethazine

A

6.25 – 25 mg IV

61
Q

Caution use of Promethazine in patients with ___

A

Parkinson’s or prolonged QT

62
Q

What are the three types of dopamine receptor antagonists?

A
  1. Phenothiazines
  2. Butyrophenones
  3. Benzamines
63
Q

Class and Use of Droperidol

A

Class: Butyrophenone

Used for PONV and sedation

64
Q

Mechanism of Droperidol

A

D2 Antagonist in the CRTZ

65
Q

Dosing for Droperidol

A

0.625-1.25 mg IV

66
Q

Caution use of Droperidol in patients with ___

A

Parkinson’s or prolonged QT (torsades de pointes)

67
Q

Class and Use of Metoclopramide

A

Class: Benzamide

Used for antiemesis, decreases gastric volume, symptomatic GERD, gastroparesis

68
Q

Mechanism of Metoclopramide

A

D2 antagoonist (CRTZ), enhances Ach resonse in upper GI tract

69
Q

Dosing of Metoclopramide

A

10 mg IV

70
Q

Acoid giving Metoclopramide to patients with __

A

GI obstruction and Parkinson’s disease

71
Q

Class & Use of Diphenhydramine

A

Class: First generation H1 receptor antagonist

Used for hypersensitivities, anaphylaxis, motion sickness, antiemesis, & sedation

72
Q

Mechanism of Diphenhydramine

A

Antagonizes H1-receptors at effector cells in the GI tract, blood vessels, and respiratory tract

73
Q

Dosing of Diphenhydramine

A

10 – 50 mg IV

74
Q

Side effects of Diphenhydramine

A

somnolence, hypotension, dry mouth, thickening of bronchial secretions

75
Q

How does scopolamine work for nausea?

A

Antagonizing the muscarinic receptor site

76
Q

Per the PONV algorithm, if prophylactic treatment has failed, use___

A

an antiemetic from a different class than the prophylactic drug

77
Q

What does the PONV algorithm suggest about Droperidol and Haldoperidol?

A

Avoid Droperidol in children unless other therapy has already failed

Use Haldoperidol only in adults

78
Q

The PONV suggests what about Scopolamine and Dexamethasone?

A

Do not re-administer either of these agents for nausea

79
Q

Dexamethasone is most effective when given ___.

A

during induction

80
Q

5-HT3 Antagonists target which receptor? Using which ligand?

Give examples

A

5-HT3 receptor

Ligand: serotonin

Examples: ondansetron, dolasetron

81
Q

Neurokinin-1 Antagonists target which receptor? Using which ligand?

Give examples

A

NK-1

Ligand: Substance P

Aprepitant (PO)

82
Q

Dopamine Antagonists target which receptor? Using which ligand?

Give examples

A

D2

Ligand: dopamine

Examples: Droperidol, Haloperidol, Metochlopramide, Prochlorperazine

83
Q

Antihistamines target which receptor? Using which ligand?

Give examples

A

H1 and M1

Ligand: Histamine & Acetylcholine

Examples: Diphenhydramine, Hydroxyzine & Promethazine

84
Q

Anticholinergics target which receptor? Using which ligand?

Give examples

A

M1

Ligand: Acetylcholine

Example: Scopolamine (transdermal)

85
Q

Steroids target which receptor? Using which ligand?

Give examples

A

Intracellular steroid receptors

Ligand: steroid

Examples: Dexamethasone

86
Q

Mechanism of Dantrolene

A

Acts directly on skeletal muscle by interfering with release of calcium ion from the sarcoplasmic reticulum; prevents or reduces the increase in myoplasmic calcium ion concentration that activates the acute catabolic processes associated with malignant hyperthermia

87
Q

Dosing of Dantrolene

A

2.5 mg/kg, continuously repeat dose until symptoms subside or a cumulative dose of 10 mg/kg is reached

88
Q

Side Effects of Dantrolene

A

Dantrolene has a potential for hepatotoxicity

Anesthesia Pharm (18 decks)

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