Drug Box 1 Flashcards
Versed Name (Generic and trade)
Midazolam
Versed Classification
Benzodiazepine
Versed contraindication
GLAUCOMA!!Pregnancy, lactation, CNS depression
Versed dose and routes
Route - IM, IV, PO
Dose - (Adults) IV: 0.5-2 mg (usual total dose 2-5 mg) IM: 0.07-0.08 mg/kg (Nagelhout HB pg. 666-667)
Induction - 0.1-0.2 mg/kg IV (Nagelhout HB pg. 110)
preop kids- 0.5 mg/kg oral (20 mg max) (Nagelhout HB pg. 970), 0.07-0.1 mg/kg IM, 0.025-0.05 mg/kg IV (Nagelhout HB pg. 1199)
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 Elimination
Half-life 1.7-2.6 hours Renal and Hepatic elimination
Versed Onset
IV: 30-60 seconds
Versed Peak
Peak - IV 2.8 - 5.6 minutes
Versed Duration
IV: 15-80 minutes
Versed misc.
Miscellaneous - Most common side effect is depression of ventilation caused by a decrease in hypoxic drive. Known for powerful amnestic effect and passes BBB. Cardiopulmonary bypass increases half-time dramatically.
Fentanyl name (generic and trade)
Trade name - (SUBLIMAZE)
Fentanyl Classification
Classification - Opioid Agonist (Nagelhout Handbook, 650)
Fentanyl Contraindications
Contraindications - Reduce fentanyl doses in elderly or hypovolemic. Crosses the placental barrier, may produce depression of respiration in the neonate. Prolonged respiratory depression after cessation of transdermal patch use.
(Nagelhout Handbook, 650)
Fentanyl Dose and Route
Dose –
Analgesia: IV: 1 to 2 mcg/kg (Nagelhout Handbook, 650)
Induction: 50-100mcg (the norm per hammon) (attempt to blunt circulatory response to direct laryngoscopy or sudden changes in level of surgical stimulation (Flood, 232))
Epidural bolus:1 to 2 mcg/kg; infusion: 2 to 60 mcg/hr
Spinal bolus: 0.1 to 0.4 mcg/kg
Dosage form: injection: 0.05 mg/mL; transdermal patch: 100 mcg/hr. In conjunction with epidural administration: 1 to 2 mcg/kg. For infusion with epidural: 2 to 60 mcg/hr. In conjunction with spinal anesthesia: bolus dose of 0.1 to 0.4 mcg/kg.
(Nagelhout Handbook, 650)
Children 2-8 years old: 15-20mcg/kg (45 minutes before induction however, use of fentanyl in pediatrics shows an increase in PONV not influenced by prophylactic doses of droperidol)
Route - Transdermal, IV, IM, Epidural/Spinal, Transmucosal
(Nagelhout Handbook, 650)
Fentanyl MOA
Mechanism of Action - 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. (Flood, 218)
Fentanyl Elimination
Elimination - Excreted by the kidneys. Less than 10% unchanged in the urine. Metabolized by hepatic P450 enzymes with the metabolites having minimal activity. (Flood, 231)
Fentanyl Onset
Onset –
IV: within 30 seconds
IM: less than 8 minutes
Epidural/spinal: 4 to 10 minutes.
Fentanyl Peak
Peak – 3.6 minutes (Flood, 32)
Fentanyl Duration
Duration –
IV: 30 to 60 minutes;
IM: 1 to 2 hours
Epidural/spinal: 4 to 8 hours.
Fentanyl Miscellaneous
Miscellaneous – Reversal Agent: (Narcan 0.2 to 0.4 mg IV). Large doses can be used as the sole anesthetic for surgery (Flood, 233).
Propofol name (generic and trade)
Diprivan
Propofol Classification
Classification: Sedative/Hypnotic
Propofol Dose and rout
Route: IV
Induction: 1.5-2.5 mg/kg
Anesthesia maintenance: 100-300 mcg/kg/min
Subhypnotic: 10-15 mg (used as antiemetic or to treat neuropathic pain)
(Flood 5th edition page 162-164)
Propofol MOA
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)
Propofol Elimination
Half time: 0.5-1.5 hours
Rapid metabolic clearance that exceeds hepatic blood flow. P450 –water soluble metabolites excreted by the kidneys. Less than 0.3% is unchanged in urine
Propofol Onset
Dose Dependent, rapid onset, less than a minute
Propofol Peak
1 min
Propofol Duration
15-45 min (depending on dose
Propofol Misc
· Can cause pain at injection site
· Does NOT trigger malignant hyperthermia
· 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
· No evidence of impaired elimination in patients with liver cirrhosis.
· Renal dysfunction does not influence the clearance of Propofol.
· Prolonged infusions may result in excretion of green urine reflecting the presence of phenols. This does not alter renal function.
· Propofol is associated with significant decreases in intraocular pressure that occur immediately after induction of anesthesia
· Can cause lactic acidosis in pediatric and adult patients with prolonged, high-dose infusions (Propofol infusion syndrome)
(Flood 5th edition pages 160-168)
Supply: 200mg/20ml
Propofol Contraindication
Avoid in patients with known hypersensitivity to Propofol, its components or have a lipid metabolism disorder
· Do not use with patients who are sensitive to sodium metabisulfite –may cause anaphylactic symptoms
· Caution is advised in elderly, debilitated, and cardiac-compromised patients
· Controversy exists regarding whether Propofol should be avoided in patients who are allergic to eggs, soy, or peanuts.
(Nagelhout 5th edition page 109)
Rocuronium Name (generic and trade)
Zemuron
Rocuronium Classification
Nondepolarizing Neuromuscular blocker
Rocuronium Contraindication
Bromide hypersensitivity and Precaution in liver pts
Dose- 0.6-1.2mg/kg (Nagelhout, p. 692) RSI dose: 1.2mg/kg (Nagelhout, p. 692)
Fasciculation dose: 10% of full dose given before propofol dose when using succs.
Rocuronium Dose and Route
Route - Intravenous
Rocuronium MOA
Binds to nicotinic acetylcholine receptors at the postsynaptic muscle membrane. Competitive antagonist of Ach
Rocuronium Elimination
Liver, Billary
Rocuronium Onset
1-3 minutes
Rocuronium Peak
1.7 mins
Rocuronium Duration
30-120 mins
Rocuronium Misc
Rocuronium can be used in patients who are hemodynamically compromised due to the less or no histamines present in the drug (Flood, p.334)
-reversal agent is Sugammadex (Nagelhout, p.1155)
-Drug of choice in RSI when succinylcholine is contraindicated (Nagelhout, p. 693)
-Enhanced muscle relaxant properties with Des (in class)
Supply: 10mg/ml
Succunylcholine Name (generic and trade)
Trade: (Anectine, Quelicin)
Succunylcholine Classification
Classification: Depolarizing skeletal muscle relaxant
Succunylcholine Contraindication
Succinylcholine should not be used for routine intubation in children younger the age of 12 because of reports of sudden cardiac arrest in children with undiagnosed Duchenne muscular dystrophy and with muscle disorders. Succinylcholine is contraindicated in patients with malignant hyperthermia, genetic variants of plasma cholinesterase or cholinesterase deficiencies, myopathies associated with elevated creatinine phosphokinase values, muscle disorders or muscular dystrophies, acute narrow-angle glaucoma, severe muscle trauma or muscle wasting, neurologic injury (i.e., paraplegia, quadriplegia, spinal cord injury, or cerebrovascular accident), hyperkalemia, severe sepsis, electrolyte imbalances, or third-degree burns over more than 25% total body surface due to potentially life threatening hyperkalemia. Repeated doses at short intervals (less than 5 minutes) are associated with bradycardia.
Succunylcholine Dose and Route
Route: IV, IM
Adults: intravenous: 1 to 1.5 mg/kg
Children: intravenous: 1 to 2 mg/kg; intramuscular: 2 to 4 mg.kg
Dosage forms: injection: 20 mg/mL; powder for infusion: 500 mg (mix in 500 mL for 1 mg/mL solution.
Succunylcholine 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)
Succunylcholine Elimination
plasma cholinesterase
Succunylcholine Onset
Onset: 30 to 60 secs
Succunylcholine Peak
Peak: 2 minutes (Nagelhout)
Succunylcholine Duration
Duration:5 to 10 minutes
Succunylcholine Misc
Pretreat with atropine because of the incidence of bradycardia.
Morphine name (generic and trade)
Astramorph PF, AVINza, Infumorph,
Duramoph PF, Embeda, Kadin
Morphine Classification
Classification: opioid agonist
Morphine Contraindication
hypersensitivity to morphine, acute/severe asthma, ↑ICP, pregnancy, severe respiratory depression, paralytic ileus, pruritus (Flood p. 228)
Morphine Dose and Route
Route: PO, IV, IM, Rectal, Epidural Doses: Nagelhout, p. 1036) (Barash, p. 515, 1231) Adult Analgesia (given 60 min prior to end of procedure): 0.15-0.2 mg/kg PACU Analgesia: 2 mg bolus q5-10 min
Intraop Anes peds: 50-100mcg/kg
PostOp peds: 50mcg/kg
Single dose Epidural: 2-5mg
Epidural Bolus adult: 3-5 mg bolus
Infusion Epidural: 0.1-1mg/hr
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
Morphine Elimination
Liver
Morphine Onset
PO 60 min IM 30-60 min IV 20 min
Morphine Peak
po 60 min
im 30-60 min
iv 30-60 min
Morphine Duration
4-5 hrs
Vecuronium Name (generic and trade)
Norcuron
Vecuronium Classification
Nondepolarizing/ Steroidal Compound) Monoquarternary neuromuscular blocker
Vecuronium Contraindications
Contraindications - caution use in patients with decreased liver and kidney function, anaphylaxis (Flood p. 331)
Vecuronium Dose and Route
Route - IV
Dose - Intubating Dose: 0.1 mg/ kg (Flood p. 329)
Vecuronium MOA
Binds to nicotinic acetylcholine receptors at the postsynaptic muscle membrane
Vecuronium Elimination
Primarily eliminated by the liver and excreted in bile (renal - 30% of administered dose) (Flood p. 331)
Vecuronium Onset
Onset - within 3 minutes (Nagelhout p. 154)
Vecuronium Peak
Peak - 2.4 min (Flood p. 329)
Vecuronium Duration
Duration- intermediate: 20-50 min (Flood p. 328)
Vecuronium Misc
Molecular instability in solution (prepared as a lyophilized powder), less potent than pancuronium, duration of block is dependent on liver function, 80% of blocking potency is from the metabolite 3-OH and long term administration can have lingering effects because of this metabolite, No histamine release so it is more appropriate for those that are hemodynamically unstable (Flood p. 334), reversed by Sugammadex
Cisatricurium name (generic and trade)
Nimbex
Cisatricurium Classification
Benzylisoquinoli-nium non-depolarizing Neuromuscular Blocking Drug
Cisatricurium Contraindication
Use caution in patients with neuromuscular diseases (myasthenia gravis, Guillian-Barre, etc). Hyperthermia may potentiate/increase duration/intensity of paralysis.
Cisatricurium Dose and Route
Route: IV push or IV infusion
4.) Dose: Intubation: 0.1-0.2mg/kg Peds Intubation: 150mcg/kg, Maintenance: 0.01-0.02 mg/kg Infusion: 1-2mcg/kg/min
Cisatricurium MOA
Nondepolarizing neuromuscular blockers compete with acetylcholine for the active binding sites at the postsynaptic nicotinic acetylcholine receptor (also called competitive antagonists) , and therefore, disallowing depolarization to occur
Cisatricurium Elimination
Hepatic
Cisatricurium Onest
2-4min
Cisatricurium Peak
3-5 mins
Cisatricurium Duration
20-50 min
Cisatricurium Misc
: Does not cause histamine release. Does not affect HR or BP, nor does it produce autonomic effects Morgan & Mikhail, p. 221) Good for renal patients
Supply: 20mg/10ml
Lidocaine name (generic and trade)
Name: Lidocaine (Xylocaine)phe
Lidocaine Classification
Class 1b antiarrhythmic agent (membrane stabilizing and mild NA channels effects) and a local anesthetic.
Lidocaine Contraindications
Do Not give this drug when PVCs occur with bradycardia or escape rhythm. May cause Seizures, Restlessness, vertigo, tinnitus, and difficulty focusing.
Lidocaine Dose and Route
Route: IV, IM, SQ, Topical, Epidural, Spinal. (Flood pg. 284,277)
Dose: 1-2 mg/kg bolus 1.5mg/kg/hr should not exceed 300mg/hr. Epidural 50-300mg max dose. Local 300mg max dose. Transdermal: 3 patches within a 24hr timeframe. (Flood, pg.277,284,299)
Lidocaine MOA
It is amide, binds to specific sites in voltage gated sodium channels blocking sodium current reducing excitability of neuronal, cardiac, CNS.
Lidocaine Elimination
Hepatic
Lidocaine Onset
45-90 mins
Lidocaine Peak
10-20 mins
Lidocaine Duration
30 mins- 4 hrs
Lidocaine Misc
May be given in conjunction with epinephrine to help increase potency and decrease systemic effects. Helps with laryngeal spasms. Also blunts the gag reflex.
Etomidate Name (generic and trade)
Amidate
Etomidate Classification
Central nervous system agent; nonbarbiturate hypnotic without analgesic activity
Etomidate Contraindications
Causes Adrenal Suppression→inhibition of cortisol, avoid in sepsis & hemorrhage (need cortisol)
Etomidate Dose and Route
Route IV
Dose-0.2-0.4mg/kg (Flood pg 169)
Etomidate MOA
- (Gaba- mimetic) Binds to GABAA receptors→increase inhibitory neurotransmitter effect.
Etomidate Elimination
Elimination - ester hydrolysis is the primary mode of metabolism in the liver and plasma
Etomidate Onset
Onset- 30seconds-60 seconds
Etomidate Peak
Peak- within 1 minute
Etomidate Duration
5-15 mins
Etomidate Misc
Miscellaneous- pain on injection (Flood pg 168-170)
Reference: book-FLOOD pg. 168-171.
Supply: 20mg/10ml
Morphine Misc
↓ dose with ESRD, monitor for delayed onset respiratory depression, Narcan 2 mg up to 10 mg, PO morphine has significant first-pass metabolism in the liver dropping the bioavailabilty of it to 25% (1 mg IV morphine ~ 4 mg PO), Less than 0.1% of IV enters the CNS (Flood p. 226-228)
