commonly used drugs Flashcards
ASA system
System to estimate medical risk
Originally designed for general anesthesia patient
Commonly known as ASA Classification
ASA classes
1,2,3,4,5,6,E
ASA 1
Normal, Healthy patient without systemic disease
ASA 2
Mild systemic disease
asa 3
Severe systemic disease, limits activity but no
incapacitating
asa 4
incapacitating systemic disease that is constant threat to life
asa 5
Not to survive 24 hours with/without operation
asa 6
Brain-dead patient awaits for organ donation
asa e
Emergency operation
Precedes number status ( i.e. ASA E-II)
ASA Classification, Definition
Normal or Usual:
Distress:
Normal or Usual: Ability to climb one flight of stairs or walk 2 level city blocks
Distress: Undue fatigue, shortness of breath, or chest pain
asa 2 examples
Type II or Non insulin dependent diabetes
Well controlled epilepsy ( no seizure in the past year)
Well controlled asthma
Hypothyroid / Hyperthyroid patient under treatment and currently euthyroid
Healthy pregnant female
> 60 y/o patient
Extreme phobic patient
Drug allergy or multiple allergies patient
Systolic 140/159mmHg and diastolic 90-94mmHg
may proceed with tx
asa 3 examples
Type I DM, well controlled patient
Symptomatic thyroid disease patient
>6 months without any residual complication
Myocardial infarction
CVA
BP (169-199) systolic / (95-114) diastolic
Epilepsy: Several seizures per year
Asthma,: Stress / exercise induced / hospitalization
Angina Pectoris (stable angina)
CHF with
orthopnea ( > 2 pillow)
Ankle edema
COPD
ASA III
No S/S of distress at rest, BUT?
tx mod
tx?
No S/S of distress at rest, BUT not under stressful situation
Serious treatment modification is needed
Yellow light for treatment ( proceed with caution
ASA IV
S/S of their medical problem when?
Their medical problem has greater significance than?
OK for ?
If invasive dental treatment is needed?
go ahead?
S/S of their medical problem at REST
Their medical problem has greater significance than
elective dental treatment
OK for non invasive dental emergency treatment
If invasive dental treatment is needed hospital
Red light for treatment ( DON’T Proceed)
asa 4 examples
Unstable Angina
<6 months without any residual complication
Myocardial infarction
CVA
BP >200 systolic / >115 diastolic
Uncontrolled dysrhythmias
Severe CHF or COPD
Wheel chair bound or need supplemental oxygen
Uncontrolled epilepsy
Uncontrolled IDD
ASA V
def
Hospitalized patient with?
dental care?
ASA V
Moribound patient not to expect to survive 24 hours\
Hospitalized patient with end-stage disease
Palliative dental care
Examples of ASA V Patients
Hospital heart valve surgery patients in need of dental
extractions
Hospital patients with end-stage organ disease in need
of palliative dental care
Patient Demographic in asa classes
Patient Demographic
ASA I or II = 85% dental patients
ASA III or IV = 14% dental patients
Sedation
Definition
Reduction of irritability or agitation by administration of
sedative drugs, generally to facilitate a medical procedure
MO Dental Board
Moderate Sedation forms
sedations?
Site Certificate for?
Moderate Sedation: Enteral, Parenteral, Pediatric
Deep Sedation / General
Site Certificate for each typ
Pediatric Patient Definition and sedations
A patient aged twelve (12) or under. The use of preoperative sedatives for children (aged twelve (12) and under) except in extraordinary situations must be avoided due to the risk of unobserved respiratory obstruction during transport by untrained individuals.
Children (aged twelve (12) and under) can become moderately sedated despite the intended level of minimal sedation; should this occur, the guidelines for moderate sedation apply.
Minimal Sedation (Anxiolysis)
Minimal sedation (Anxiolysis)—A minimally depressed level of consciousness produced by a pharmacological method, which retains the patient’s ability to independently and continuously maintain an airway and respond normally to tactile stimulation and verbal command. Although cognitive function and coordination may be modestly impaired, ventilatory and cardiovascular functions are unaffected. Note: In accord with this particular definition, the drug(s) and/or techniques used should carry a margin of safety
wide enough never to render unintended loss of consciousness. Further, patients whose only response is reflex withdrawal from repeated painful stimuli would not be considered to be in a state of minimal sedation. When the intent is minimal sedation for adults, the appropriate initial dosing of a single enteral drug is no more than the maximum recommended dose (MRD) of a drug that can be prescribed for unmonitored home use
minimal sedations for kids
The use of preoperative sedatives for children (aged twelve (12) and under) except in extraordinary
situations must be avoided due to the risk of unobserved respiratory obstruction during transport by
untrained individuals. Children (aged twelve (12) and under) can become moderately sedated despite the
intended level of minimal sedation; should this occur, the guidelines for moderate sedation apply.
NO with anxiolytics
Nitrous oxide/oxygen may be used in combination with a single enteral drug in minimal sedation.
Nitrous oxide/oxygen when used in combination with sedative agent(s) may produce minimal, moderate, or deep sedation or general anesthesia.
Moderate Sedation (Conscious Sedation)
A drug induced depression of?
Generally, no interventions are required to?
Cardiovascular function?
Moderate Sedation (Conscious Sedation)
A drug induced depression of consciousness during which
patients respond purposefully to verbal commands, either alone
or accompanied by light tactile stimulation.
Generally, no interventions are required to maintain a patent
airway, and spontaneous ventilation is adequate.
Cardiovascular function is usually maintained
Deep Sedation
A drug-induced depression of ? during which?
The ability to independently maintain ventilatory function?
Patients may require assistance in?
Cardiovascular function?
Deep Sedation
A drug-induced depression of consciousness during which
patients cannot be easily aroused but respond purposefully
following repeated or painful stimulation.
The ability to independently maintain ventilatory function may be
impaired.
Patients may require assistance in maintaining a patent airway
and spontaneous ventilation may be inadequate.
Cardiovascular function is usually maintained.
Qualified Sedation Provider
Qualified sedation provider—Any of the following who have
satisfied the provisions of this rule:
1. A currently licensed dentist in Missouri with a valid permit to
administer enteral, parenteral, or pediatric moderate sedation
2. A currently licensed anesthesiologist
3. A currently licensed certified registered nurse anesthetist.
Common Medication used in IV Sedation
Barbiturate
Propofol
Ketamine
Benzodiazepine
Opioids
Opioids General Properties
Desirable Effects
Analgesia
Sedation
Euphoria
Anti-tussive
Undesirable Effects of opioids
Respiratory Depression
Coma
Emesis
Constipation
Histamine release
Potential for addiction
Miosis
Mechanism of action
Significance?
All Addicts demonstrate?
Mechanism of action
○ Edinger-Westphal nucleus of Oculomotor nerve
○ Enhanced parasympathetic stimulation
Significance?
○ Most other causes of coma and respiratory depression produce
mydriasis (dilation of pupil)
All Addicts demonstrate pin-point pupils
Opioids Mechanism of Action
mu, kappa, delta, sigma
endogenous opioids
Endorphins
Enkephalins
Dynorphins
Morphine
The Gold Standard?
Pharmacology
routes?
moa?
lipophilicity?
Onset? peak?
T ½
Duration of action :
Do not give to?
The Gold Standard of pain med
IM / IV
Hyperpolarize nerve cell, ↓release of substance P
Least lipophilic minimum crossing to BBB
Onset 5-10mins, peak within 30mins
T ½ 1.5 – 2 hours
Duration of action : 4-6 hours
Do not give to neonate (unable to conjugate)
morphine metabolism
Conjugate with glucuronic acid
○ Morphine-6-glucuronide (potent analgesic)
○ Morphine-3-glucuronide (inactive)
Morphine
Elimination
End product eliminated by kidney
Renal failure patient may have narcosis and vent failure for days !
morphine adrs
Fentanyl
potentcy?
Pharmacology
routes?
effects?
lipophilicity?
Onset? peak effect in?
Duration
Fentanyl
100X potency of morphine
Oral / IV / Transdermal
Analgesic and Sedative effect
High Lipid solubility rapid onset / short duration
Onset of action < 60 sec with peak effect in 2 – 5 mins
Duration 30 – 60 mins
fent Metabolism
Inactive metabolite
○ Remember the “end “ of the effect is due to redistribution!!
○ Fentanyl will accumulate in body fat with repeated injections
Fentanyl
Elimination
Little effect on renal patient
Clearance dependent on hepatic blood flow
fent adr
No histamine release like morphine
Rigid Chest Syndrome
○ After large drug bolus !!
Naloxone (Narcan)
Mechanism of Action
Competitive antagonist at opioid receptors
Greater affinity for μ receptors than κ or δ receptor
naloxone Pharmacology
Reversal of ?
rate?
duration?
○ why?
T ½
○ implication
Reversal of endogenous or exogenous opioid compound
Rapid antagonizing (1-2 min)
Brief duration of action (30-45 mins) IV
○ Rapid redistribution from CNS
T ½ is only 30–80 mins
○ Respiratory depression may linger despite “alert/awake” appearance
naloxone dose
IV administration of 0.4mg IV (Titrate to effect !!!)
Naloxone (Narcan)
Recommended usage
Any suspicion of?
○ Support?
○ Check?
Continue sluggish response
○ Rule out?
○ Consider giving?
Any suspicion of OD
○ Support respiration (O2 and continue monitoring)
○ Check oxygen saturation, vital signs
Continue sluggish response
○ Rule out hypoglycemic shock, CVA, Psychotic episode
○ Consider giving IM, if concern for re-sedation give 0.4mg IM
naloxone adrs
Abrupt reversal = Excessive catecholamine release
○ tachycardia, hypertension, ventricular irritability
May antagonize Clonidine
Nausea/Vomiting may be observed
Benzodiazepines
General properties
Sedation
Anxiolysis
Muscle relaxation
Anterograde amnesia
Anticonvulsant effect
common side effects of benzodiazepines
Fatigue
Drowsiness
Respiratory depression !
are benzos an analgesiac?
no
Benzodiazepines
Mechanisms of Actions
Enhances inhibitory effect of neurotransmitters
Facilitates GABA receptor binding
↑membrane conductance of Chloride ions
enhances inhibitory effect of GABA
Diazepam
IM injection?
Pharmacology
insoluble in? leads to>
CNS uptake?
Benzodiazepines
Diazepam
IM injection of diazepam is painful and unreliable
Pharmacology
Water-insoluble therefore…..
Propylene glycol + Sodium Benzoate added but pain upon injection
Rapid uptake by CNS due to high lipid solubility
diazepam metab
Hepatic microsomal enzyme = Desmethyldiazepam + Oxazepam
Desmethyldiazepam is metabolized slowly =sustained effects !
Phase 1 metabolites of diazepam are pharmacological active
diazepem elimination
Long half-life 30 hours
Midazolam
Oral Administration is?
Pharmacology:
localirritant?
potnent?
solubilities?
○ at physiologic pH?
Midazolam
Oral Administration is NOT approved by FDA but commonly used
No local irritation
2-3X more potent than diazepam
Water soluble at low pH
Lipid soluble at high pH
○ Imidazole ring closes at physiologic pH
Midazolam
metabolism, elim, placenta, paradox?
Flumazenil (Romazicon)
Mechanism of Action
Competitive antagonist of benzodiazepine receptors
flumazenil usage
Usage
Reversal of benzodiazepine sedation and/or overdose
Prompt (<1min) hypnotic reversal, Amnesia is ?
Respiratory depression may linger despite “alert/awake” appearance
flumazenil Dosage
IV administration of ? until reversal
repeated doses, why>
T ½
IV administration of 0.2mg every min until reversal
Due to rapid hepatic clearance, repeat dose may be needed in 1-2 hours
T ½ is only ~ 1 hour
flumazenil Side Effects
May induce?
Increases?
GI
May induce seizure activity
Increase Catecholamines
○ ↑ BP and heart rate
Nausea/Vomiting may be observed
The most Frequently administered General Anesthesia induction
agent
Barbiturates
Barbiturates
Mechanism of Action:
Enhance GABA inhibitory neurotransmitter
barbs site of actions
Depress reticular activating system
○ Polysynaptic network responsible for consciousness
Common Barbiturates
Thiopental
Methohexital (Brevital)
Phenobarbital
Propofol / Diprivan
Mechanism of action, results in?
Largely replacing?
Enhance GABA inhibitory function = ↑Cl channel = increases hyperpolarization of cell membrane
Results Rapid onset of unconsciousness
Arterial and venous dilatation
Largely replacing Thiopental (Barbiturates)
Ketamine
used for?
moa
affects?
Sympath?
General Anesthesia Medicine
Selective NMDA receptor blocker
Dissociative, Hallucinogenic and Amnesic Effect
Sympathomimetic medicine (ADRs)
ketamine cons
Hallucinogenic, Nightmare emergence, Increase Salivary flow
