Box 1 Flashcards
Generic name for Versed?
Midazolam
Classification of Versed?
Benzodiazepine
Contraindications for Versed?
GLAUCOMA!
lactation, pregnancy, CNS depression
Usual dose of Versed given before Intubation?
2-5mg
If Versed is used as the sole medication in intubation how much would you give?
0.1-0.2mg/kg IV
Versed dose for pre-op kids?
0.5mg/kg oral (20mg max)
Versed MOA?
binds to GABA receptor increases the frequency of chloride channel opening, resulting in postsynaptic membrane hyperpolarization and neuronal transmissions is inhibited.
Versed Elimination half-time?
Half-life 1-3 hours
Versed onset IV?
30-60 sec.
Versed Peak IV?
2-6 min.
Does Versed pass through the BBB?
Yes
Versed is supplied in the vial as what concentration?
5mg/ml or 2mg/ml
Reversal for Versed?
Flumazenil
If Versed is given for paradoxical vocal cord motion and/or strider post surgery, how much will you give?
0.5-1mg IV
How fast should you push Versed?
over 2 min (slowly)
Trade name for Fentanyl?
Sublimaze
Classification of Fentanyl?
Opioid Agonist
Contraindications to Fentanyl?
If elderly or hypovolemic, reduce dose.
Crosses the placenta and may produce depression of respiration in the neonate.
May have prolonged respiratory depression after cessation of TD patch.
Induction dose of Fentanyl?
50-100 IV mcg is normal
Why do we give Fentanyl before intubation?
attempt to blunt circulatory response to direct laryngoscopy.
Why is Fentanyl given before or during surgery?
blunt sudden changes in level of surgical stimulation.
Analgesia dose of Fentanyl for adults?
1 to 2 mcg/kg
Epidural bolus dose of Fentanyl, and infusion rate?
bolus: 1 to 2 mcg/kg (same as analgesic dose)
infusion: 2 to 60 mcg/hr
Spinal dose of Fentanyl?
one time dose of 0.1-0.4mcg/kg
Fentanyl MOA?
Opioids mimic the actions of enkephalins, endorphins, and dynorphins (endogenous ligands) by binding to opioid receptors, resulting in activation of pain-modulating (antinociceptive) systems.
Causes analgesia and anesthesia.
Fentanyl IV onset?
within 30 sec.
Epidural/Spinal onset of Fentanyl?
4-10 min.
Duration of Fentanyl:
IV
Epidural/spinal
IV 30-60 min.
Epidural/Spinal 4-8 hours
Reversal for Fentanyl?
Narcan 0.2 to 0.4 mg IV
Fentanyl typically comes supplied in a vial as what concentraiton?
250mcg/5ml
Trade name for Propofol?
Diprivan
Classification of Propofol?
Sedative/Hypnotic
Contraindications with Propofol?
lipid metabolism disorder
sensitivity to sodium metabisulfite (can cause anaphylasis)
Caution in the elderly, debilitated (low blood pressure obviously) and cardiac-compromised patient (L sided heart disorders)
if allergic to eggs, soy, or peanuts some controversy exists if those patients should have propofol
Propofol dose for Induction?
1.5-2.5mg/kg IV
Propofol maintenance Anesthesia dose?
100-300mcg/kg/min
Propofol dose if used for antiemetic or to treat neuropathic pain?
10-15 mg
MOA of Propofol?
Increases GABA affinity for GABAa receptor. This decreases the rate of disassociation of the inhibitory neurotransmitter GABA from the receptor and increases the duration of the GABA-activated opening of the chloride channel which leads to hyperpolarization of cell membranes (inhibition of the cell).
(keeps the chloride channel open longer)
Elimination half time of propofol?
30min. - 90 min.
Propofol Onset?
RAPID onset that is dose dependent, less than 1 min.
Peak: Propofol?
1 min.
Duration of Propofol?
15-45 min. depending on dose.
What may you want to tell someone before you IV push Propofol?
May cause burning or pain at injection site.
How long can you keep an ampule of propofol, when does tubing need to be changed and why?
Strongly supports growth of E-coli & Pseudomonas aeruginosa. It is recommended that the contents of an unused ampule be discarded after 6 hours, and in the ICU the tubing and any unused portion be discarded after 12 hours.
Renal and Liver issues in relation to Propofol use?
No evidence of impaired elimination in patients with liver cirrhosis.
Renal dysfunction does not influence the clearance of Propofol.
Color of urine with prolonged propofol use and why?
Prolonged infusions may result in excretion of green urine reflecting the presence of phenols. This does not alter renal function.
IOP and propofol use?
Propofol is associated with significant decreases in intraocular pressure that occur immediately after induction of anesthesia. (Intubation would increase IOP, so propofol lowering it is a good thing.)
With prolonged high dose infusion of propofol what metabolic issue can occur?
Lactic acidosis
Propofol is typically supplied in a concentration of what out the vial?
200mg/20ml
Rocuronium Trade name?
Zemuron
Rocuronium Classification?
Nondepolorizing NMB
Contraindications with Rocuronium?
Precaution in liver patients
Bromide hypersensitivity.
Dose of Rocuronium?
fasciculation dose, full intubating dose, and RSI dose
fasciculation dose is 10% of a full dose given before propofol dose when using succs.
intubating dose: 0.6-1.2mg/kg
RSI dose: 1.2mg/kg
MOA of Rocuronium?
Binds to nicotinic acetylcholine receptors at the POSTsynaptic muscle membrane. Competitive antagonist of Ach.
Onset: Roc?
1-3 min.
Peak: Roc?
1.7 min (min and a half)
Duration: Roc?
30-120 min.
Reversal agent for Rocuronium?
Sugammadex!
When used with Desflurane which NMB has enhanced muscle relaxation?
Rocuronium
Drug of choice for RSI if succ. is contraindicated?
Rocuronium
If a patient is hemodynamically compramised which muscle relaxant will you most likely want to use? why?
Rocuronium, due to less or no histamine release.
Rocuronium comes supplied as a concentration of what in the vial?
10mg/ml
Trade name for Succinylcholine?
Anectine (also Quelicin)
SCh Classification?
Depolorizing NMB
Contraindications to SCh?
Do not use in pts. with hx of MH, cholinesterase deficiencies, muscular disorders, severe muscle trauma or wasting, neurologic injury, and acute narrow- angle glaucoma.
Do not use if burns over 25% or more of TBS (transient hyperkalemia)
Do not repeat doses in intervals of less than five min!
SCh dose for intubation in Adults and in Children?
Adults: 1-1.5mg/kg
Children: 1-2mg/kg
SCh MOA?
SCh binds to (at least one) the a sub units of the nicotinic acetylcholine receptor in the NMJ. Because SCh is not hydrolyzed by acetylcholinesterase, the channel remains open for a longer period of time than would be produced by acetylcholine, resulting in a depolarizing block (sustained depolarization prevents propagation of an action potential).
Elimination half time of SCh?
47 sec.
Onset: SCh
30-60 sec.
Peak: SCh
2 min.
Duration: SCh
5-10 min
Why does SCh have such a short duration?
The short duration of action of succinylcholine is due to its rapid hydrolysis by butyrylcholinesterase (plasma cholinesterase) to succinylmonocholine and choline, such that only 10% of the administered drug reaches the neuromuscular junction.
Recovery from succinylcholine-induced blockade occurs as succinylcholine diffuses away from the neuromuscular junction, down a concentration gradient as the plasma concentration decreases.
There is little or no butyrylcholinesterase at the neuromuscular junction
What can you pretreat with if you are going to use SCh and are worried about bradycardia?
Atropine
When are cardiac dysrhythmias likely to occur with SCh use?
When a dose is given within 5min. of a prev. dose.
What electrolyte issues can occur due to SCh?
Hyperkalemia, which is transient increase of 0.5mEq/dL, generally well tolerated by individuals with normal potassium to start with.
IOP and SCh use?
increases IOP which peaks at 2-4 min. and returns to normal by 6 min.
What can SCh cause, potentially limiting it’s use?
MH
What supply does SCh typically come as, concentration in vial?
20mg/ml in the vial
Classification of Morphine?
opioid agonist
Morphine Doses: Adult Analgesia PACU analgesia Single dose Epidural Epidural Bolus Adult Infusion Epidural
Adult Analgesia (given 60 min prior to end of procedure) = 0.15-0.2 mg/kg
PACU Analgesia: 2 mg bolus q5-10 min
Single dose Epidural: 2-5mg
Epidural Bolus adult: 3-5 mg bolus
Infusion Epidural: 0.1-1mg/hr
Onset: Morphine IV and epidural?
IV 20min
Epidural 60-90 min.
(PO is 60min. and IM is 30-60min.)
Peak: Morphine IV and epidural?
IV 30-60min.
epidural 30-60min.
(IM is the same, and PO is 60min.)
Duration: Morphine IV and Epidural?
IV 4-5 hr
epidural 8-24 hr
(PO and IM is 4-5hr)
Morphine MOA?
Mu1 and Mu2 agonist, ↑ threshold to pain and modifies the perception of noxious stimulation, poor lipid solubility, K+ channel opening and inhibition of Ca++ channel causing inhibition of ascending pathway.
Metabolism of Morphine?
Hepatic; conjugation forms morphine-3- glucuronide (75-85%) and morphine-6-glucuronide (5-10%)
Morphine 6 is stronger than normal Morphine.
Adverse reactions to Morphine?
histamine release, hypotension, bradycardia, N/V, bronchospasm, spasm of sphincter of Oddi, confusion, sedation, constipation.
Contraindications to Morphine?
hypersensitivity to morphine, acute/severe asthma, ↑ICP, pregnancy, severe respiratory depression, paralytic ileus, pruritus.
If you have Renal dz, what will you do to the Morphine dose?
decrease dose with ESRD.
Reversal for Morphine OD?
Narcan 2mg and up to 10mg.
What is the equivalent of 1mg IV Morphine to PO dose?
1mg IV Morphine = 4mg PO Morphine
Does Morphine given IV go into the CNS easily?
No, morphine is very water loving and does not pass the BBB much at all, only 0.1% of morphine IV enters the CNS.
Trade name for Vecuronium?
Norcuron
Classification of Vec.
(Nondepolarizing/ Steroidal Compound) Monoquarternary neuromuscular blocker
Contraindications to Vec. use?
caution use in patients with decreased liver and kidney function.
Intubating dose of Vec?
0.1 mg/ kg
MOA of Vec.?
Works the same way as Rocuronium, competes with ACh for postsynaptic nicotinic receptors (cholinergic) and produces muscle relaxation.
Elimination of Vec?
liver half life is 78 min
Onset of Vec?
Peak of Vec?
Duration of Vec?
O: within 3 min.
P: 2.4 min.
D: 20-50 min.
Is Vec less or more potent than pancuronium?
Less potent
Does vecuronium have histamine release?
NO histamine release, more appropriate for those that are hemodynamically unstable.
What can reverse Vecuronium?
Sugammadex
Duration of a Vec. Block is dependent on what organ function?
liver function
Vec. comes supplied in a vial concentration of?
1mg/1ml
What neuromuscular blockers can be reversed with Sugammadex?
Rocuronium
Vecuronium
and
Trade name for Cisatricurium?
Nimbex
Classification of Cisatricurium?
Benzylisoquinoli-nium non-depolarizing Neuromuscular Blocking Drug
Contraindications to Cisatricurium use?
Hypothermia
and use with caution in patients with neuromuscular dz (MG, Gullian-Barre)
Inutbating dose of Cisatricurium?
0.1-0.2 mg/kg
same as Versed only intubating dose
MOA of Cisatricurium?
Same as Roc and Vec.
Nondepolarizing neuromuscular blockers compete with acetylcholine for the active binding sites at the postsynaptic nicotinic acetylcholine receptor (also called competitive antagonists) , and therefore, not allowing depolarization to occur
Elimination of Cisatricurium?
HOFMANN elimination, Hepatic.
Onset
Peak
Duration
of Cisatricurium?
Onset: 2-4 mins Peak: 3-5 mins
Duration: Intermediate 20-50 min
Does cisatricurium cause histamine release?
No!
Histamine release is NOT associated with which NMB?
Cisatricurium
Vecuronium
Rocuronium (none/little)
Cisatricurium is supplied as a vial concentration of what?
2mg/ml
Lidocaine’s other name?
xylocaine
Classification of Lidocaine?
Class 1b antiarrhythmic agent.
LA
Contraindications of Lidocaine use?
Do Not give this drug when PVCs occur with bradycardia or escape rhythm.
(I assume this is in relation to IV dosing and not LA use?)
What is the max dose of lidocaine when used as an Epidural or Local?
Epidural 50-300mg max dose.
Local 300mg max dose.
Dose of Lidocaine for intubation, (and why are you giving it for intubation?)
1-1.5mg/kg (same as Sch dose)
blunts gag reflex and helps with laryngeal spasms.
How many patches of Lidocaine can someone have in a 24 hour period?
3 patches
Infusion rate and max dose of Lidocaine?
1.5mg/kg/hr
should not exceed 300mg/hr
MOA of Lidocaine?
It is amide, binds to specific sites in voltage gated sodium channels blocking sodium current reducing excitability of neuronal, cardiac, CNS.
Elimination of Lidocaine (hepatic or Renal?)
Hepatic
Onset
Peak
Duration
of Lidocaine?
O: 45-90 sec.
P: 10-20 min.
D: 30 min. to 4 hours
What can be given with Lidocaine to help increase potency and decrease systemic effects?
epinephrine
Lidocaine typically comes supplied as a vial concentration of what?
dependent on the % lidocaine you use, For Matt it was 2% so 20mg/ml
Etomidate trade name?
Amidate
Classification of Etomidate?
Central nervous system agent; nonbarbiturate hypnotic without analgesic activity
Contraindications to Etomidate use?
Causes Adrenal Suppression→inhibition of cortisol, avoid in sepsis & hemorrhage (they need cortisol)
Dose for intubation with Etomidate?
0.2-0.4mg/kg
MOA of Etomidate?
(Gaba- mimetic) Binds to GABAA receptors→increase inhibitory neurotransmitter effect.
Etomidate
Onset:
Peak:
Duration:
Onset- 30-60 sec.
Peak- within 1 minute
Duration- 5-15 min.
Etomidate is supplied in a concentration of?
2mg/1ml
