Barbiturates/non-barbiturates Agents Flashcards
Why are barbiturates not classify as either short acting or long acting
- Residual plasma concentrations last for hours even after “ultra short-acting” drug are given for anesthesia
- More drug will convert a short acting to long actin
Ultra short Barbiturates
Methohexital
They are _________solutions so they are incompatible with _____, _____ and _______ (NOC)
Alkaline salts
Opioids, catecholamines, NMB agents
Methohexital usually ___% with a ph of ____-
1; 10
Barbiturates comes from a combination of the
urea and malonic acid.
Methohexital ________causes _____activity manifested by __________
Methyl radical (methohexital), causes convulsive activity manifesting as involuntary muscle movement
**Mechanism of action for Methohexital
- Works on neurotransmitter GABA in the CNS/ potentiates effect (inhibitory neurotransmitter)
- Produces sedative-hypnotic effects
GABA to cell work by?
Hyperpolarize post synaptic cell
Barbiturates and propofol on GABA, Mechanism of action
Barbiturates and propofol
⇩ dissociation of GABA from receptor
⇧duration of GABA activated opening of chloride channels
Barbiturates on RAS ______
• RAS promotes_________
- Uniquely depress reticular activating system(RAS)
- wakefulness(⇧ Brain activity)
- leading to hypotension due to venodilation
At high doses , barbiturates does what?
⇩ sensitivity of postsynaptic membranes to acetylcholine inhibits Ach to bind to Ach receptors enhances muscle relaxation
***Fast awakening with methohexital is because
*****redistribution from the brain to inactive tissues
Elimination of methohexital is dependent on ______%metabolized
metabolism• <1% recovered unchanged in the urine (99% metabolized)
Methohexital
Effect site equillibration is _________
and Context sensitife half life is ________due to
Rapid effect site equilibration
prolonged ; drug sequestered in fat and skeletal muscle reenters the circulation
Protein binding parallels_________
• Decreased protein binding due__________ such as aspirin can =
- lipid solubility
-to displacement by drugs - enhanced drug effects
⇧ drug sensitivity in pts with uremia and cirrhosis
what can decrease protein binding in uremic patients ?
⇩ protein binding in uremic pts may be due to
competitive binding of nitrogenous waste products
(displacement by metabolites)
_________cause ⇩ protein binding in pts with_________
Hypoalbuminemia ;cirrhosis of the liver
Most important determinant of DISTRIBUTION
Lipid solubility
2 Other determinants of distribution other than lipid solubility
Ionization
Protein binding
For Methohexital the most important determinant of distribution is
Lipid solubility
__________is a major determinant of delivery- change in blood volume/flow may alter distribution
Tissue blood flow
***Methohexital in the brain undergo_______within _______
What is the mechanism of early awakening?
Methohexital undergo maximal brain uptake within
30 seconds
•Redistribution is the mechanism for early awakening after SINGLE IV dose
_________is the most prominent site for initial redistribution of high lipid soluble barbiturates
Skeletal muscle
During distribution • Initial ____plasma concentration________due to
• Equilibration with skeletal muscle is achieved in _______after IV dose of ________
⇩ ; uptake into skeletal muscles
15 minutes after IV does thiopental
• Need to ____dose with muscle ______perfusion (shock), _____muscle mass (elderly)
⇩;⇩; ⇩
Metabolism of Methohexital
Metabolized where?
Reserve capacity of liver is _______therefore takes ______dysfunction before you have a prolonged effect.
Oxybarbiturates metabolized only in hepatocytes
• Reserve capacity of liver is large -> takes extreme
hepatic dysfunction before a prolonged effect
Methohexital vs thiopental which has more rapid metabolism? reflecting less________
Therefore______ remains in plasma= more available for
metabolism
methohexital rapid ;lipid soluble
More
Methohexital Hepatic clearance is______than thiopental
• Early awakening after single IV dose is dependent
on _________
3-4 X more than thiopental
redistribution
For methohexital _________plays a greater role in terminating effects, than________
• Metabolism plays a role in time required for
complete____________
Metabolism; THIOPENTAL ;
psychomotor recovery
• Psychomotor functions recover faster with-______than ________
methohexital than thiopental
For Methohexital vs Thiopental: recovery time ?
more predictable doses than thiopental
What is more dependent on changes in cardiac output and hepatic blood flow ?
Hepatic clearance
Barbiturates are excreted where?
Renal system
All barbiturates filtered by renal glomeruli:
What limits filtration?
What favors reabsorption into circulation ?
What % is excreted unchanged?
• High degree of protein binding limits filtration
• High lipid solubility favors reabsorption of filtered
drug back into circulation
• <1% methohexital is excreted unchanged in urine
_________ and _________are similar for thiopental and methohexital
Distribution half time and Vd
_______ and _______differ for methohexital and Thiopental
• Elimination half time and clearance
Why is methohexital shorter elimination half time due to ?
• Methohexital’s shorter elimination half time due to
it’s greater hepatic clearance
Elimination half time of methohexital is_____
Thiopental ______
about 4 hours; 11 hours
• Principal uses of methohexital
Induction anesthesia
• Treatment of ⇧ ICP
• Electroconvulsive therapy
• Seizure treatment
Barbiturate use is declining due to 5 main reasons among many
Lack specificity of effect in the CNS
Lower therapeutic index than benzodiazepines
Result in tolerance more easily than benzodiazepines
Greater liability for abuse
Paradoxical reaction in elderly
What drug has replaced barbiturates?
Propofol has replaced barbiturates
• Especially when rapid awakening is desired
This drug has more rapid recovery of consciousness
Methohexital
What is the only barbs with actions sufficient to offer an alternative to other IV induction agents?
Methohexital
2 Disadvantages of Methohexital?
⇧ incidence of excitatory phenomena such as involuntary skeletal muscle movements(myoclonus) and hiccough
• High dose associated with seizures in 1/3 patients
The involuntary skeletal muscle movement is -_____dependent therefore premedicate with
• Incidence-dose dependent, can ⇩ by premedicate
with opioids & use optimum dose of (1-1.5mg/kg)
Potency and dose
Methohexital vs thiopental? which one more potent and why?
when dose redistribution terminates action ?
Methohexital is 2.5 x more potent than thiopental
⇧ potency is due to lower ionization at physiologic
pH/ Alkaline=burns on injection
- about 8.5 minutes
What is the dose of Methohexital dose?
1-1.5mg/kg
High dose response curve?
NMB agents, 80-90% of receptors to exert an effect.
Alkaline drugs
Burn on injection
For uncooperative patients, give methohexital
rectally ; 20-30mg/kg
Other uses of Methohexital for neurology ? USe to during
Useful to induce seizures
• ECT
• Temporal lobe resection of seizure producing
tissue
Barbs used to_____ICP, along with_____&_______. ⇩
• Barbs _____metabolic oxygen requirements
⇩ hyperventilation & diuresis
⇩
How does barb decrease ICP?
by decrease cerebral blood volume through drug
induced cerebral vasoconstriction and associated ⇩
in cerebral blood flow
Barb on EEG and head trauma patient
- Isoelectric EEG=max barb effect and ⇩ CMRO2 55%
* No improved outcomes for head trauma pt
Barb High dose =________ = ____cerebral perfusion
pressure
hypotension;⇩
Methohexital
• Dose required to suppress EEG results in _________ & ___________ similar to isoflurane (2 MAC)
vasodilation & myocardial depression
When profound EEG depression is desired? _____ preferred over ____
Barbs is preferred to Isoflurane if profound EEG depression is desired
Methohexital Cerebral protection?
Improve brain survival in cardiac patients?
Not recommended for routine _____surgery due to _____ and _________
_______may be protective without prolonging recovery.
No improved brain survival in cardiac arrest
patients
• Not recommended for routine use during cardiac
surgery due to ⇧ need for inotropic support and
prolonged recovery time
• Hypothermia may be more protective without
prolonging recovery
Methohexital Side Effects : Cardiac
CV depression
Normovolemic pt- transient 10-20 mmHg ⇩ in BP
and offset by compensatory 15-20BPM ⇧ in HR
Overdose or large dose to ⇩ ICP may cause direct
myocardial depression
Methohexital on induction
What happens to BP?
3 reasons?
Induction- mild, transient ⇩ BP due to peripheral
vasodilation (mostly venous), reflecting depression of the medullary vasomotor center and ⇩ sympathetic nervous system outflow
Barb and hypovolemic patients?
2 classes of drugs that worsen conditions?
Caution , hypotension may occur
Beta blockers and centrally acting alpha 2 agonists
may accentuate this response= more profound
shock
For induction of anesthesia, barbs produce a dose
dependent depression of _______and ______ventilatory centers.
• Leads to 3 things?
depression of the medullary and pontine ventilatory centers
⇩ response to hypercarbia
• Low respiratory rate
• Low tidal volumes
2 drugs with higher risk for MH
Succinylcholine
Volatile anesthetics
⇧_______when used with other CNS depressant
drugs used for preop medication
Apnea risk
Large doses needed to suppress _____and ________
laryngeal reflexes & cough
May occur during intubation?
Laryngospasm or bronchospasm may occur during intubation attempts- no LMA
Induction dose doesn’t alter_________
Induced enzyme induction =
-postop LFT’s
accelerated metabolism of other drugs (oral anticoagulants, phenytoin, tricyclic antidepressants) or endogenous substances (corticosteroids, bile salts and vit K)
• Stimulate ________in liver metabolism (____)
after 2-7 days sustained drug administration
⇧ in liver metabolism (enzyme inducer)
Barbiturates stimulate activity of ___________ which leads to _____Production of ______ and may exacerbate which condition ?
• Stimulate the activity of mitochondrial enzyme
• This ⇧ production of Heme, and may exacerbate
acute intermittent porphyria
Barbiturates, avoid in pt with _____________
Avoid in pt with Acute Intermittent Porphyria
• Also enhance barbs own metabolism which
contributes to tolerance
Barbiturates lead to a Modest _____in renal blood flow and glomerular filtration rate due to
⇩; ⇩ in BP and CO
Does barbiturate use for induction of anesthesia produce renal damage?
• Barbiturate use for induction of anesthesia does not
produce renal damage
Barbiturates and placenta?
Fetal plasma conc vs. maternal concentration
Barbiturates readily cross the placenta
• Fetal plasma concentrations are significantly lower
than maternal plasma concentrations
______occurs earlier than enzyme induction
At maximal tolerance the required effective dose
increases _______
- Acute tolerance
- six-fold
Tolerance to the sedative effects occurs
sooner and is greater than the anticonvulsant and lethal effects
As tolerance to the sedative effects\_\_\_\_ the therapeutic index\_\_\_\_\_\_(narrow therapeutic index)
⇧; ⇩
With intra-arterial injection there is ?
Can cause _____ and ________
Risk ___with ___drug concentration
Immediate, intense vasoconstriction and excruciating pain that radiates along the distribution of the artery
Gangrene and permanent nerve damage may result
Risk ⇧ with ⇧ drug concentrations
Mechanism of Damage done with intra-arterial injection
Precipitation of crystals in the artery leading to inflammation and arteritis, which coupled with the micro embolization that follows causes • Occlusion of the distal artery • Ischemia • Tissue necrosis
Intra-arterial injection
Treatment-immediate attempts to dilute drug,
prevention of arterial spasm, general measures to
maintain blood flow
Lidocaine, papaverine, phenoxybenzamine sympathectomy of the upper extremity produced by a brachial plexus block
Large role in picking out induction agents
Blood pressure
Etomidate doest not
increase or decrease BP or CO
Which induction agents will raise BP
Ketamine
Which 2 induction agents with analgesic ?
Precedex
Ketamine (potent analgesic properties)
Venous Thrombosis happens because of?
Deposition of barbiturate crystals in the vein
• Less risk because of ⇧ diameter of veins
• Prevented by using dilute concentrations
(1% methohexital )
Allergic reactions for IV barbs for induction of anesthesia most likely represent anaphylaxis but can also be anaphylactoid. What is the difference?
• Anaphylaxis- antigen-antibody interaction,
immune mediated and requires prior exposure
• Anaphylactoid- no previous exposure or
sensitization, not a true allergic reaction but results
in histamine release, vasodilation, wheals, and
welts
Treatment for allergic reaction of barbiturates
• Treatment- Aggressive fluid replacement & IV EPI
What are the NON- BARBITURATE INDUCTION AGENTS ?
PDEK Propofol (Diprivan), Dexmedetomidine(Precedex) Etomidate (Amidate) Ketamine (Ketalar)
What is PROPOFOL?
is it chemically different as compared to other IV sedatives?
Emulsion (parental fat formulation intralipid)
1% (10mg/ml)solution in an aqueous solution of 10% soybean oil, glycerol, and purified egg lecithin
FketaminChemically different from all other IV sedative/ hypnotics
Equivalence of propofol to thiopental?
1.5-2.5mg/kg IV is equivalent to 4-5mg/kg thiopental or 1.5 mg/kg methohexital
Dose of Propofol induction
1.5-2.5 mg/kg rapid IVP=unconsciousness in 30 seconds