BOX 1 DRUGS Flashcards
Versed generic name
Midazolam
Versed classification
Benzodiazepine
Versed induction dose (not the sole induction medication)
2mg-5mg is typical, 2mg more often
Versed MOA
(CNS depressant) MOA - binds to GABA receptor exerts its actions by modulating chloride channels (GABA receptor increases the frequency of chloride channel opening, resulting in postsynaptic membrane hyperpolarization and neuronal transmissions is inhibited)
Versed induction alone dose
0.1-0.2mg/kg IV
Versed onset, peak, duration?
Onset - IV: 30-60 seconds
Peak - IV 2.8 - 5.6 minutes
Duration - IV: 15-80 minutes
Versed how fast should it be pushed?
Should push midazolam slowly over 2 minutes.
Fentanyl trade name?
Sublimaze
Fentanyl classification
opioid agonist
Typical Induction dose of Fentanyl?
Exact induction dose of Fentanyl?
Typical 50-100 mcg
Exact 1-2 mcg/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, peak, duration?
onset - within 30 sec
Peak- 3-4 min
Duration-30-60 min
Fentanyl reversal agent?
Reversal Agent: (Narcan 0.2 to 0.4 mg IV).
Fentanyl misc. information?
Large doses can be used as the sole anesthetic for surgery.
Used as an induction agent to reduce the amount of other sedation medications.
Fent. IV dose for analgesia in adults?
1-2mcg/kg
Versed reversal?
Flumazenil
Versed pediatric oral dose and IV dose
oral - 0.5mg/kg (MAX 20mg)
IV - 0.025-0.05mg/kg IV
Children dose of fentanyl?
15-20mcg/kg (45 min before induction)
fentanyl in kids usually causes what?
PONV
Fent. patch dose (typically)
75-100mcg/hr (change q 3 days)
Fentanyl epidural bolus and maint. infusion?
1-2 mcg/kg bolus
and then infusion of 2-60mcg/hr
Fent. spinal bolus?
0.1-0.4mcg/kg
propofol trade name is?
diprivan
propofol classification?
sedative/hypnotic
Propofol MOA
Increases GABA affinity for GABAa receptor. This decreases the rate of disassociation of the inhibitory NT, GABA from the receptor and increases duration of GABA opening of chloride channel which leads to hyperpolorization of cell membrane. (inhibition of cell)
propofol induction dose?
1.5-2.5mg/kg IV
Propofol anesthesia maintenance?
100-300mcg/kg/min
Propolfol Onset, Peak, Duration
O: less than a min. dose dependent
P: 1 min.
D: 15-45 min, dose dependent
When would you NOT use propofol?
If someone has L sided heart issues or great cardiac output issues (lowers blood pressure) then you would use etomidate.
Prolonged use of propofol can cause three things (misc.)
green urine
lactic acidosis
supports bacterial growth, change lines q 12 hours and throw away ampules q 6 hours
Rocuronium Trade name?
Zemuron
Roc. classification?
Non-depolorizing NMB
contraindication to Roc?
bromide hypersensitivity and precaution in liver pts.
Roc dosing? (normal, RSI, fasciculating dose)
Normal = 0.6-1.2 mg/kg RSI = 1.2 mg/kg Fasciculating = 10% of full dose before propofol with SCh.
Roc. MOA?
Binds to Nicotinic receptors on postsynaptic muscle membrane (where ach is supposed to bind) competes with ach for these binding sites causing no depolarization and flaccid paralysis.
Roc onset, peak, duration
O: dose dependent, if you want it closer to a min then use the 1.0-1.2mg/kg dose
could take up to 3 min. with smaller doses.
P: 1.7 min
D: 30-120 min.
Reversal for Roc?
Sugammadex
When is Roc the drug of choice?
When succinylcholine is contraindicated in RSI or the patient has history of or we are worried about MH.
When would the duration of Roc be prolonged? what kind of patients?
patients with liver or renal issues
SCh trade name?
Anectine, Quelicin
SCh classification
depolorizing skeletal muscle relaxant
SCh MOA
Partial agonist against the nicotinic acetylcholine receptor (nAChR) and depolarizes (opens) the ion channels. This opening requires the binding of only one molecule of SCh to the α subunit. The other α subunit can be occupied by either acetylcholine or SCh. 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)
SCh ADULT dose?
Adult IV 1.0-1.5 mg/kg
SCh child dose? IV and IM
IV 1.0-2.0 mg/kg
IM 2-4 mg/kg
SCh onset, peak, duration?
Onset: 30-60 sec
Peak: 2 min
Duration: 5-10 min
What are some things you need to know before giving SCh or some reasons that would have you question giving it? (misc)
If given again within five min. of first dose then cardiac dysrhythmia can occur, may want to pre-treat with atropine.
can increase potassium (hyperkalemia) 0.5 mEq/L (well tolerated in healthy individuals) bc of this you do not wan’t to use in someone with over 25% burns or crush injuries.
DO NOT USE in anyone with family or self history of MH or plasma cholinestrase deficiency.
increased IOP, ICP
What is interesting about SCh half life?
very short half-life of 47 sec, meaning that the plasma cholinesterase is very good at clearing it out.
reversal for SCh?
Does NOT have a reversal, just wait for it to clear.
What is acetylcholinesterase?
acetylcholinesterase is what degrades or clears out acetylcholine from the NMJ, it does not work on SCh which must be cleared by plasma cholinesterase.
Morphine classification?
opioid agonist
Morphine dose for pre op adult analgesia?
adult post op analgesia?
pediatric intraop analgesia?
pediatric post op analgesia?
pre op adult = 0.15-0.2mg/kg
post op adult = 2mg bolus q5-10 min.
pediatric intraop = 50-100mcg/kg
pediatric post op= 50mcg/kg
Morphine IV onset peak duration?
Morphine IV onset: 20min
peak: 30-60 min
Duration: 4-5 hours
Morphine MOA?
Mu1 and Mu2 agaonsit, increases threshold to pain and modifies the perception of noxious stimulation. causes inhibition of ascending pathway through potassium channel opening and inhibiting calcium channel.
Metabolism of Morphine occurs where and what does it make?
Liver, makes morphine 3 and morphine 6, morphine 6 (5-10%) is stronger than regular morphine.
adverse reactions morphine can cause?
histamine release
hypotension, N/V, sedation, constipation, spasm of sphincter of Oddi, bronchospasm.
CONTRAINDICATIONS to morphine?
hypersensitive to morphine
acute/severe asthma (due to histamine release)
increased ICP, pregnancy, sever respiratory depression
paralytic ileus, pruritus.
reversal for morphine? (same as fent.)
Narcan 2mg, up to 10mg
Trade name for Vecuronium?
Norcuron
Vec. classification
nondepolorizing NMB
Monoquarternary
Vec intubating dose?
0.1mg/kg
MOA for non depolorizing NMB? (includes Roc, Vec, Nimbex)
Binds to Nicotinic receptors on postsynaptic muscle membrane (where ach is supposed to bind) competes with ach for these binding sites causing no depolarization and flaccid paralysis.
Vecuronium onset, peak, duration?
onset- within 3 min
peak- 2.4 min
duration- 20-50 min
Reversal for Veuronium?
sugammadex
other name for cisatricurium?
Nimbex
Nimbex also goes by?
Cisatricurium
Cisastriucurium classification?
non depolorizing NMB
Benzylisoquinoli-nium
Intubating dose of cisastriucurium? For adults
for children?
Adults = 0.1-0.2mg/kg IV Children = 150mcg/kg
Maintenance dose for cisastriucurium (prolonged paralysis)
0.01-0.02mg/kg/min or 1-2mcg/kg/min
Cisastriucurium onset, peak, duration?
onset 2-4 min
peak 3-5 min
duration 20-50 min
Other name for Lidocaine?
Xylocaine
Lidocaine classification?
Class 1b antiarrhythmic agent (membrane stabilizing and mild NA channel effects)
LA
Contraindications to Lidocaine?
Do not give when PVC’s occur with bradycardia or escape rhythm.
Dose of Lidocaine IV induction
Epidural
Local
Transdermal
IV 1.0-2.0 (1-1.5) mg/kg (dosing in induction) same as bolus dose before maintenance (1.5mg/kg/hr)
Epidural 50-300mg max dose
Local 300mg max dose
Transdermal 3 patches in a 24 hour period
Lidocaine MOA
Binds to specific sites in voltage gated sodium channels blocking sodium current and reducing excitability of neuronal, cardiac, CNS. (it is an Amide)
Lidocaine onset, peak, duration?
onset 45-90 sec
peak 10-20 min
duration 30 min - 4 hours
If you give lidocaine with epinephrine what happens?
helps increase potency and decrease systemic effects.
Why is lidocaine given during induction?
helps with laryngeal spasms (decreases them)
What does lidocaine do to the gag reflex?
blunts the gag reflex
Trade name for etomidate?
Amidate
Etomidate classification?
non barbiturate hypnotic (without analgesia)
Dose for Etomidate?
0.2-0.4mg/kg IV
Etomidate MOA
Binds to GABAa receptors causing an increase inhibitory nerotransmitter effect (opening of cl- channel). hyperpolorizing the cell.
Etomidate Onset, peak, duration?
Onset 30-60 sec
Peak within 1 min
Duration 5-15 min
When would you use Etomidate?
Induction- instead of propofol, does not drop cardiac related hymodynamics like propofol does.
most common side effect of Versed?
depression of ventilation caused by decrease in hypoxic drive
How much versed would you give for paradoxical vocal cord motion or stridor post surgery?
0.5-1 mg IV
What powerful effect does Versed have and why?
powerful amnestic effect bc it does pass through the BBB
Where does elimination of Versed occur?
renal and hepatic elimination
half life of Versed?
1.7-2.6 hours
Can Versed pass through the BBB?
Yes!
most common side effect of Versed?
depression of ventilation caused by a decrease in hypoxic drive.
Does cardiopulmonary bypass increase the half-time of Versed?
Yes, dramatically
What would be the dose of Versed for paradoxical vocal cord motion and stridor-post surgery?
0.5-1mg IV
Versed would be contraindicated with what disorders?
Glaucoma
CNS depression
How does Versed typically come in the vial?
5mg/ml or 2mg/ml
Who metabolizes Fentanyl?
Hepatic p450
Elimination of Fentanyl?
excreted by kidneys, less than 10% unchanged in urine.
Why do you use Fentanyl during induction or surgery?
attempt to blunt circulatory response to direct laryngoscopy or sudden changes in level of surgical stimulation.
supply of fentanyl in the vial?
250mcg/5ml
If someone has a lipid metabolism disorder what induction med would you not use with them?
Propofol
What induction med is contraindicated in patients who are elderly, debilitated, and cardiac- compromised?
Propofol
Half life of propofol?
.5-1.5 hours
where does metabolism of propofol take place and where is it eliminated?
Rapid metabolic clearance that exceeds hepatic blood flow. P450 –water soluble metabolites excreted by the kidneys. Less than 0.3% is unchanged in urine.
If you have liver or Kidney dysfunction, will that influence the elimination or clearance of Propofol?
NO
Is propofol known to increase IOP?
No, it is associated with lowering IOP.
How does propofol come typically in a vial?
200mg/20ml
Roc is eliminated where?
LIVER, Billiary
The supply or typical vial dose of Roc is what?
10mg/ml
What Volatile gas potentiates Roc’s muscle relaxant properties?
Desflurane
Can Rocuronium be used in patients who are hemodynamically compromised?
Yes, due to less or no histamines present in the drug.
What is the typical amount in a vial of Succs
20mg/ml
Why would you pretreat Succs with atropine?
incidence of bradycardia
How is Succs metabolized and where is it excreted?
90% metabolized by cholinesterase in the plasma.
10% excreted unchanged by the kidneys.
How long before the end of a procedure would you give Morphine to provide Analgesia? What would the dose be?
60 min prior to the end of the procedure. Dose of 0.15-0.2mg/kg
Morphine, tell me about its first pass metabolism?
has significant first-pass metabolism in the liver dropping the bioavailabilty of it to 25% (1 mg IV morphine ~ 4 mg PO)
Morphine, is it known to be more water soluble or lipid soluble?
water soluble, this accounts for why less than 0.1% of an IV dose enters the CNS.
what patients should you use caution with if wanting to give Vecuronium?
caution use in patients with decreased liver and kidney function, anaphylaxis (Flood p. 331)
Half life of Vecuronium?
78 min
metabolism and excretion of Vec?
Primarily eliminated by the liver and excreted in bile (renal - 30% of administered dose) (
Does Vec have histamine release and why does this matter?
No, and bc it does not have histamine release it makes the drug more suitable for hemodynamically unstable patients.
Vec. is supplied in the vial as?
1mg/ml
Is the duration of the block of Vec. dependent on liver, kidney, or plasma function?
duration of block is dependent on liver function.
Vec produces a metabolite known as 3-OH, what is the significance of that?
80% of blocking potency is from the metabolite 3-OH and long term administration can have lingering effects because of this metabolite
What type of elimination does Nimbex go through?
Hofmann Elimination (Hepatic)
Does Nimbex cause histamine relsease?
NO!
How is Nimbex supplied in the vial for use?
20mg/10ml
How is HR and BP affected by Nimbex?
Does NOT affect HR or BP.
Nimbex is good for use in what type of patient, like you would specifically choose it for this reason?
Renal patients
Where is lidocaine metabolized?
Hepatic
Lidocaine is supplied to us in the vial as what amount?
10mg/ml
Etomidate is supplied in what amount?
20mg/10ml
Contraindications for Etomidate use?
Causes Adrenal Suppression→inhibition of cortisol, avoid in sepsis & hemorrhage.
Metabolism of Etomidate?
ester hydrolysis is the primary mode of metabolism in the liver and plasma.
