Chem/Diuretics/Aging Flashcards
12-13 questions ch 22, 42, 46
What three things does the kidney secrete?
- Calcitriol
- Renin
- Erythropoetin
What things do chemo drugs target?
malignant cells and other quickly proliferating cells such as hair, skin, bone, and gi mucosa
What labs should be conducted preop for individuals on chemotherapy?
EKG, CXR, Hemoglobin , platelet count, WBC, coag profile, ABGs, blood glucose, Electrolytes, LFT, renal function tests
What chemotherapeutic agent causes acoustic nerve injury and nephrotoxicity?
Cisplatin (leads to unsteadiness and increased falls)
What chemotherapeutic agent causes peripheral neuropathy?
vincristine,blastine
What chemotherapeutic agent causes pulmonary fibrosis?
Bleomycin
What chemotherapeutic agent causes cardiotoxicity?
doxorubicin
What 2 chemotherapeutic agents cause bone marrow suppression?
5-fluorouracil and methotrexate
Why are there so many side effects of chemotherapeutic drugs and what are they??
narrow therapeutic index caused tissue damage to nonmalignant cells
n/v, myelosuppression, mucositis, and alopecia
How do alkylating agents
(nitro must, alk sulf, nitrosour, triaze) work?
inhibit plasma cholinesterase and covalently binds to RNA and DNA protiens, activity for 2-3 weeks post admin (bone marrow supp. most limiting SE)
What is an anesthesia consideration for alkylating agents?
Can lead to prolonged skeletal muscle paralysis after giving succinylcholine (due to inhibitor of plasma cholinesterase 2-3 weeks)
What drug is frequently used in Hodgkin’s disease and what are the side effects?
Mechlorethamine: n/v, myelosuppression
What chemo drug treats myelogenous leukemia and what are side effects?
Alkyl sulfonates, se: pulm fibrosis
Elim by kidneys
What class is cisplatin in, MOA, and side effects?
Plastinating drugs, similar MOA to alkylating drugs (inhibit DNA replication)
SE: loss of proprioception, neurotoxicity, renal toxicity (limiting dose and causing AKI/ATN), ototoxicity
What types of cancer does cisplatin treat?
lung, bladder, testicular, and ovarian
What chemo drug could be a contraindication for regional anesthesia?
Cisplatin due to subclinical neurotoxicity and potential to mask a nerve injury that already occurred
What drug is an antimetabolite, indication, moa, and side effects?
Methotrexate, hemo and non hemo cancers, ped leukemia, inhibits folate that is used in dna/rna production
SE: BMS, gi effects, pulm tox (edema), hepatic dysfnctn, renal insuff, alopecia, dermatitis
Which chemo drug can cause death due to intestinal perforation?
Methotrexate
What are topoisomerase inhibitors, MOA, indications, and side effects?
Doxorubicin/Daunorubicin enzymes that control the 3d structure of DNA/alter dna synthesis, treats leukemia
SE: free radicals hurt cardiac antioxidant defenses > cardiotox,
Doxorubicin/Daunorubicin considerations
dont cross BBB, red urine 1-2 days, cardiac concerns, CHF, LF failure for up to 3 years
previous treatment with what chemo drug can cause enhanced myocardial depressant effects related to anesthesia? (even with normal cardiac function)
doxorubicin
What is the sign of acute doxorubicin cardiomyopathy?
dry nonproductive cough- fatal in 3 weeks after in 60% of patients
Major bleomycin side effects
pulm tox: type 1 and 2, interstitial fibrosis
s/s: cough, dyspnea, and basilar rales
ranges from mild-severe
How should patients with bleomycin induced respiratory side effects be managed?
administer FiO2 at <30%, don’t give excessive crystalloid (give colloids to prevent interstitial edema), can give albuterol
Vincristine indication, moa, and side effects
Hodgkin disease, non-Hodgkin lymphoma, and peds solid tumors
neuropathy, paresthesia, foot drop, skeletal m pain, loss of achilles reflex, CN issues, hypotension, tremors
What is a major consideration for preop management of patients taking chemo drugs?
aggressive PONV treatment: Emend, Marinol, Scope patch, ondansetron, promethazine
What drug can be used off label to produce analgesia effects in patients taking chemo drugs?
Tricyclic antidepressants
What is an example of a loop diuretic, where do they work in the nephron, and what is the MOA?
furosemide, medullary thick ascending loop of henle, inhibit reabsorption of na, k, and cl by impairing transporter in medullary portion of thick ascending loop. 20-30% filtered na reabsorbed here
What is an example of a carbonic anhydrase diuretic, where do they work in the nephron, and what is the MOA?
acetazolamide (diamox), noncompetitive inhibition of enzyme activity in proximal convoluted tubule, decreases na and hco3 reabsorption
What is an example of a thiazide diuretic, where do they work in the nephron, and what is the MOA?
hydrochlorothiazide, cortical ascending loop of henle, decrease na reabsorption and therefore decreased fluid reabsorption
What is an example of a osmotic diuretic, where do they work in the nephron, and what is the MOA?
mannitol, inhibit water reabsorption in the proximal convoluted tubule and the thin descending loop of Henle and collecting duct
What is an example of a potassium sparing diuretic, where do they work in the nephron, and what is the MOA?
Amiloride, collecting duct, selectively blocks na transport, inhibiting sodium-potassium exchange
What is an example of a aldosterone blocker diuretic, where do they work in the nephron, and what is the MOA?
spironolactone, collecting duct, increases na and h2o secretion while retaining k
What diuretic is used as first line therapy for hypertension?
thiazides (also, osteoporosis, resistant HTN, decrease edema)
What diuretic is first line for renal impairment?
Loop diuretics (also treats hypertension, and acute HF)
What diuretic is used to decrease intracranial pressure?
osmotic diuretics (other: prevent periop AKI)
What diuretic class is used as an adjunct to loop/thiazide therapy?
Potassium sparing diuretics (also: enhance diuresis, limit K loss, cystic fibrosis)
What diuretic class is used for altitude sickness and glaucoma?
carbonic anhydrase inhibitors
also used for idiopath intracranial htn, familial periodic paralysis, stimulate resp drive (hyperchloremic metabolic acidosis), central sleep apnea
What are the three primary indications for diuretic therapy?
used for htn and heart failure
to increase urine flow and promote diuresis
blocks sodium reabsorption at different points along the nephron
What are side effects of carbonic anhydrase inhibitors?
fatigue, decreased appetite, depression, and paresthesia
What are side effects of loop diuretics?
fluid/electrolyte imbalances, hypok, hight BG, increased dig tox, “braking phenomenon”, low BP, and ototox
Furosemide metabolism, onset, half life, and dosing:
highly protein bound, renal: 50% tubular secretion, 50% conjugate in kidneys, onset 5-10 min, peak 30min 1/2 life 1-2 hrs,
D; 40mg norm renal fnctn, CRF: 160-200mg
What is an administration consideration for loop diuretics?
push slowly to prevent ototoxicity
Thiazide diuretics are contraindicated in what disease?
renal insufficiency
What are the side effects of thiazide diuretics?
Orthostatic HOTN, Hypokalemia,Hypochloremia, Hyponatremia, Hypomagnesemia, Increase aldosterone, Hypercalcemia, Glucose intolerance, Hyperlipidemia
What are the anesthesia considerations for Thiazide diuretics?
increased effects of NDMB
NSAIDs decrease effectiveness
high risk of lithium tox
What are side effects of osmotic diuretics?
Pulm edema, hypovolemia, hypokalemic, hypochloremia alkalosis, plasma hyperosmolarity
What are the indications and side effects for aldosterone antagonists?
I: Essential HTN, Refractory HTN, “Aldosterone Escape”, Edema & fluid overload
SE: high K, gynecomastia, breast tenderness
Which potassium-sparing diuretic antagonizes aldosterone at the mineralocorticoid receptors?
Spironolactone
How does advanced age affect mortality and heart function?
increased mortality, decreased heart function
Why do elderly individuals poorly tolerate being in Afib?
their heart depends on atrial kick for ventricular filling due to diastolic dysfunction
How does advanced age affect the respiratory system?
less lung compliance and poor cough reflex (high risk for aspiration)
How does advanced age affect coagulability?
Increased clotting factors which results in hypercoag
How does advanced age affect body temperature management?
decreases temp, changes in regulation
What are two adverse effects of anesthesia that more commonly occur in older individuals?
vomiting and delirium (increase blood pressure to decrease chances)
What results from chemo induced myelosupression?
pancytopenia (increased need for transfusion)
What is an anesthesia consideration for alkylating agents?
decreases pulm compliance due to pulm fibrosis (high risk of barotrauma)
What are platinating drugs made of?
platinum
What chemo drug contraindicates use of general anesthesia and why?
cisplatin, can cause tumor proliferation/rogue cell migration
What two drugs are frequently given to decrease risks of renal toxicity w/ cisplatin
mannitol and lasix
What could giving methotrexate to a pregnant woman cause?
neural tube defect in baby due to lack of folate
What chemo drug cannot be given with recent live vaccine?
methotrexate
What chemo drug is frequently used to treat testicular cancer?
bleomycin
What diuretics should not be used in patients with a sulfa allergy?
carbonic anhydrase inhibitors
Why are carbonic anhydrase inhibitors given to decrease intraocular pressure?
carbonic anhydrase increases production of aqueous humor (fluid in eye)
Overall, what are the effects of diuretics on chloride and potassium?
increase chloride, decrease potassium
What are the effects of diuretics on cardiac function?
decreases
What paralytic agent should be deeply considered prior to administration with diuretics and why?
succs because they patient could have hypokalemia which would alter efficiency of drug
What type of diuretic is isosorbide and what is its primary indication?
osmotic, heart failure
What is important to remember about aldosterone antagonists?
they cause hormonal changes
How does advanced age affect response to opioids?
more sensitive to medications and have a larger respiratory depressive effect
What drug should never be given with chemo and why?
Ketamine, decreases cardiac effects
What are the two volatiles of choice for patients on chemo?
iso and des
Physical signs of moon face and buffalo hump could indicate:
Cushing syndrome
Why do patients receiving cisplatin have a high risk for falls?
vestibular neurotoxicity with balance
What should be given to prevent neurotoxicity r/t cisplatin use?
mannitol and lasix
NSAIDs and Salicylates cause ______ drug level when given with __________.
increased, methotrexate
how does acetazolamine influence pH?
decrease bicarb reabsorption that causes alkaline urine. treats metabolic alkalosis (leads to metabolic acidosis)
off label tx for kidney stones
which diuretic exhibits potential for sulfa allergy cross reaction?
carbonic anhydrase inhibitor
what is a major factor regarding the bioavailability of loop diuretics?
protein level due to excessive protein binding
which diuretic increases risk of kidney stones and why?
thiazides due to calcium reabsorption
What are the most impactful physiological changes that accompany aging?
alteration in hepatic and renal function
What drugs are older individuals especially sensitive to and what is our response?
propofol, fentanyl, midazolam
give smaller doses, higher pain threshold, require less anyways
(also have prolonged NMB effects)
What is a pharmacokinetic consideration for elderly individuals?
they have low serum protein levels and more body fat which results in a larger volume of distribution which can cause longer medication effects (esp in the setting of kidney/renal dysfunction)
What two drugs increase the risk for delirium in older adults?
ketamine and volatile gases
What anesthetic management should be practiced regarding the respiratory and neuro system in older adults?
provide COMPLETE reversal prior to extubation to prevent aspiration due to WEAK pharyngeal muscles
