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Advanced Pharm For NA 1 > Exam 2 Study Guide > Flashcards

Exam 2 Study Guide Flashcards

1
Q

Sevoflurane (Ultane)
-MAC %
-B/G Partition Coefficient
-O/G Partition Coefficient

A

2%
0.6
50 -potent

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2
Q

Isoflurane (Forane)
-MAC %
-B/G Partition Coefficient
-O/G Partition Coefficient

A

1.15%
1.4
99 -very potent

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3
Q

Nitrous Oxide
-MAC%
-B/G Partition Coefficient
-O/G Partition Coefficient

A

105%
0.47
1.4 -not potent at all

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4
Q

Desflurane (Suprane)
-MAC%
-B/G Partition Coeffficient
-O/G Partition Coefficient

A

5.8%
0.42
18.7 -not very potent

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5
Q

Halothane (Fluothane)
-MAC%
-B/G Partition Coefficient
-O/G Partition Coefficient

A

0.75%
2.3
224 -very potent

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6
Q

MAC and potency is _ proportional

A

inversely

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7
Q

How blood/gas solubility of drug influences uptake/distribution:

A

lower the coefficient= faster anesthetic rises in lungs; faster induction + emergence
higher the coefficient= slower anesthetic rises in lungs; slower induction + emergence

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8
Q

How CO influences uptake/distribution:

A

If CO increases, onset of all anesthetics SLOW (Palv)
-affects SLOW drugs more than FAST drugs bc of Fa/Fi ratio-increased CO removes drug at quicker rate
-ISO uptake is affected the most

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9
Q

How oil/gas solubility influences uptake/distribution:

A

describes potency; if highly potent it is slow to go in, slow to come out; halothane most potent, N20 least
-high OG solubility = more potent
-low OG solubility = less potent

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10
Q

How V/Q deficits influence uptake/distribution: which drugs are effected most?(3)

A

less than normal lungs go to sleep slower than normal lungs
-there is a decrease in onset rate especially for LOW blood/gas coefficient or more INSOLUBLE drugs-N2O, SEVO, DES
-sports car slows down much faster than old beater can

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11
Q

All volatile anesthetics are _ _ . The _ protects the compound making it more stable and _ being added prevents the molecule from being metabolized into toxic byproducts

A

halogenated ethers
Halogen
Fluorine

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12
Q

The only inorganic anesthetic gas is _

A

Nitrous oxide (no carbon group)

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13
Q

Amnesia is the loss of memory and acts on the _ and _

A

hippocampus
amygdala

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14
Q

Unconsciousness is controlled through the _, _, and _.

A

cortex
thalamus
brainstem

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15
Q

Analgesia is the loss of pain and occurs through the _ _

A

spinothalamic tract

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16
Q

Immobility is the loss of motor control and occurs thru the _ _ and the _ _ _

A

spinal cord
central pattern generators

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17
Q

CNS effects of anesthesia are _ -dependent with _ requiring the lowest dose (MAC) followed by sedation, unconsciousness, and immobility.

A

dose dependent
amnesia

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18
Q

In general, CNS and ANS are _ with volatile anesthetics

A

depressed

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19
Q

T/F Volatile anesthetics are cerebral-protective with antioxidant effects that prevent damage to cells

A

True

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20
Q

5 effects of anesthesia gases on neuological system

A
  1. ICP
  2. Autoregulation of CBF and cerebral reactivity to CO2
  3. Cerebral metabolic rate of O2 (CMRO2)
  4. CSF Pressure
  5. Neuro assessments (obviously)
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21
Q

The brain’s ability to autoregulate cerebral perfusion pressure depends heavily on the MAP being in the range of _ to _.

A

60-180
CPP = MAP - ICP

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22
Q

Volatile anesthetics _ the capacity of the brain to autoregulate CPP.

A

REDUCE
-it does this REGARDLESS of if the MAP is within the window of 60-180

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23
Q

When trying to compensate for increased ICP, cerebral vasodilation, and increased CBF we can _ the dose/MAC and/or hyperventilate the pt to achieve goal of PaCO2 _ - _ to prevent further vasodilation.

A

reduce
30-35 PaCO2

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24
Q

All inhaled anesthetics (and most IV anesthetics) will _ MEPs, but _ will do so the most.

A

decrease
Isoflurane

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25
Q

Almost all inhaled and IV anesthetics decrease SSEPs except _ and _ which increase them

A

Etomidate
Ketamine

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26
Q

Of the IV anesthetics, only _ increases CBF, CMRO2, ICP, SSEPs, and CPP/MAP

A

ketamine

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27
Q

Unlike the other inhaled anesthetics, _ doesn’t have a large affect on CMRO2 and ICP

A

N2O

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28
Q

Increasing the dose of anesthetics will typically cause decreased BP EXCEPT in which 4 anesthetics(usually)?

A

N20
Ketamine
Etomidate
Precedex

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29
Q

The 5 factors that cause BP to fall during anesthesia are:

A

1.CNS depression
2. Direct Cardiac Depression
3. Dose dependent decrease of SVR leading to vasodilation
4. Baroreceptor Depression (aortic arch, carotids)
5. Hormonal changes (decreased renin, vasopressin release)
-all anesthetics do this EXCEPT N2O

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30
Q

When giving epinephrine, doses should be no stronger than:
1: _ = _ mg/mL
No more than _ mL (or _ mg) in a 10 minute period.
No more than _mL (or _ mg) in an hour total.

A

1:100,000 ~ 0.01mg/mL
10mL (0.1mg)
30mL (0.3mg)
-volume administered can be adjusted by changing concentration of the dose

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31
Q

Which (main) inhaled anesthetic can cause tachycardia due to respiratory irritation and what is a first line intervention for this?

A

Desflurane
Fentanyl IV

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32
Q

The inhaled anesthetics all lower MAP and SVR EXCEPT

A

N2O
-can increase SVR, no effect on MAP

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33
Q

The inhaled anesthetics all increase HR EXCEPT

A

Sevoflurane

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34
Q

Which 2 inhaled anesthetics are known to lower CO?

A

Isoflurane and N2O

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35
Q

All inhaled anesthetics bronchodilate and cause dose dependent respiratory depression EXCEPT

A

N2O

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36
Q

Which 2 inhaled anesthetics are respiratory irritants?

A

Desflurane and Isoflurane

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37
Q

Unlike opiates, the respiratory depressant nature of inhaled anesthetics (except N2O) causes _ to decrease before _.

A

Vt
RR

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38
Q

All inhaled anesthetics (besides N2O) decrease _, which decreases renal _ _, decreasing _, which then will cause decreased _

A

BP
renal blood flow
GFR
UOP

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39
Q

Which inhaled anesthetic has the highest rate of toxic metabolites?

A

Sevoflurane 5-8%
-don’t give to renal pts
-lasts longer in obese pts

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40
Q

Which inhaled anesthetic is known to cause hepatotoxicity?

A

Halothane

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41
Q

Which inhaled anesthetics can trigger MH and therefore are contraindicated in pts at risk?

A

ALL EXCEPT N2O
-Succinylcholine too!

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42
Q

N2O oxidizes the cobalt atom on _ _, inhibiting _ _ which disrupts DNA/RNA synthesis.

A

Vitamin B 12
Methionine Synthetase

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43
Q

Which inhaled anesthetic can cause immunosuppression in at risk pts?

A

N2O

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44
Q

What are 3 absolute contraindications for giving N2O?

A
  • Known B12 deficiency
  • Toxicity from expansion of gas in space
  • Increased ICP
    -others include: 1st Tri pregnancy, pulm HTN, high risk PONV, risk of MI, PROLONGED CASE (>6hr)
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45
Q

CO2 absorbers can get dry and produce _ during a case if the machine hasn’t been used in a while

A

CO

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46
Q

In regards to CO2 absorbers, Compound A can form when “low flow _” is given usually at flow rates < _L/min

A

low flow Sevo
<2L/min
-newer CO2 absorbers don’t react with Sevo

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47
Q

Which anesthetics/OR drugs can worsen cancer/ risks?

A

Volatile anesthetics
Opiates
Supplemental O2

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48
Q

Which 3 anesthetics are helpful against cancer risks/growth?

A

Local Anesthetics
NSAIDs
Propofol

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49
Q

The only inhaled anesthetic proven as teratogenic is _ and it is contraindicated in pregnancy (not delivery) due to its risk for spontaneous abortion

A

N2O

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50
Q

Chance of miscarriage is highest within first _ days postop and inhaled anesthetics are known to make the uterus _ (although N2O is the only confirmed teratogenic drug)

A

7
boggy

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51
Q

Kids between the ages of _ _ and _ years of age can experience neurotoxicity from inhaled anesthetics and should have cases kept short if possible.

A

third trimester
3yo

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52
Q

Pediatric Emergency Delirium (ED) is a short term condition that is seen usually after _ or _ is used during a case and can be treated by small doses of other IV anesthetics (midazolam, fentanyl, ketamine, etc.)

A

sevoflurane
desflurane

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53
Q

Female CRNAs can experience higher likelihood of miscarriage or birth defects when exposed to cases involving: (3 items)

A
  1. N2O
  2. Xray imaging (ortho cases)
  3. peds cases (mask induction often)
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54
Q

Male CRNAs are more likely to produce children who are _.

A

female

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55
Q

T/F Inhaled anesthetics don’t pass the placental-fetal barrier.

A

false, they ALL do

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56
Q

Non-urgent surgeries should occur during the _ trimester in pregnant women.

A

2nd

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57
Q

Most IV anesthetics (EXCEPT _) pose significant neurodevelopmental risk.

A

precedex

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58
Q

GA during emergent CS has no association with learning disability but it does with _.

A

Autism

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59
Q

In addition to N2O, two main drug classes that are considered teratogenic are:

A

Anticonvulsants and Antipsychotics

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60
Q

If given close to delivery, sedatives and hypnotics can cause _ _ in the newborn.

A

respiratory depression

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61
Q

Exposure to opioids in early pregnancy can cause congenital _ _

A

heart defects

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62
Q

T/F Muscle relaxants can cross the placental barrier.

A

False

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63
Q

NAIDs are contraindicated during pregnancy and have different negative outcomes for different trimesters:
1.
2.
3.

A

1.spontaneous abortion
2.congenital cryptoracism
3. renal injury and constriction of ductus arteriosus

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64
Q

The vasopressor of choice for pregnant patients is _

A

Ephedrine

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65
Q

Ionizing radiation is considered teratogenic and can cause _ _ thru gestational weeks 8-15 and childhood _

A

mental retardation
leukemia :(

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66
Q

T/F Heparin and Abx are ok in pregnancy

A

true

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67
Q

T/F quinolone, tetracycline, and codeine are ok in pregnancy

A

false

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68
Q

Age of viability of a fetus:

A

24 wks

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69
Q

Fast recovery of anesthesia is _ proportional to the solubility of the med

A

inversely

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70
Q

T/F A longer case will cause a longer emergence

A

true

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71
Q

Which inhaled anesthetic can cause seizure on EEG?

A

Sevoflurane = Seizurflurane

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72
Q

MAC peaks at _ months old

A

6

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73
Q

Sevo
-Boiling point
-Vapor Pressure

A

58*C
157

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74
Q

Des
-boiling point
-vapor pressure

A

24*C
669

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75
Q

Iso
-boiling point
-vapor pressure

A

49*C
238

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76
Q

N2O
-boiling point
-vapor pressure

A

-88*C
38,770

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77
Q

Which inhaled anesthetic boils at room temp and is easiest to vaporize?

A

Desflurane
-vapor pressure is close to 760

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78
Q

It takes _ half lives to get rid of a drug.

A

4

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79
Q

How much of a drug is gone after 3 half lives?

A

87.5% is gone
12.5% is left

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80
Q

Common drugs in benzo class:

A

diazepam (vallium)
lorazepam (ativan)
midazolam (versed)
flumazenil (romazicon)

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81
Q

Common drug in butyrophynone class:

A

Droperidol (Inapsine)

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82
Q

Common induction drugs in miscellaneous classes:

A

Propofol (Diprivan)
Etomidate (Amidate)
Ketamine (Ketalar)
Dexmedetomidine (Precedex)

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83
Q

Common drugs in barbiturate class:

A

Thiopental (Petothal)
Metohexital (Brevital)
Phenobarbital (Luminal)
Pentobarbital
Secobarbital

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84
Q

Alpha half life is how long it takes from drug to go from _ to _ and is due to drug _

A

blood to tissue
distribution

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85
Q

Beta half life is how long drug takes after distribution to be 50% _ and is due to drug _.

A

eliminated
metabolism

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86
Q

_ of _ is a number that indicates how widely a drug is distributed in the body

A

Volume of Distribution (Vd)

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87
Q

Normal Vd for a 70kg pt is about _L or _L/kg

A

42L or 0.6L/kg

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88
Q

A smaller Vd (<0.4L/kg) means the drug is mainly contained in the _ and is _ solube

A

plasma
water

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89
Q

A larger Vd (>0.6L/kg) means the drug is mainly contained in the _ and is _ soluble

A

body
lipid

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90
Q

_ has the longest elimination half life out of the IV anesthetics at 20-50hrs.

A

Diazepam (Valium)

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91
Q

Common heavily (>90%) protein bound IV anesthetics include: (5 items)

A

Diazepam, Lorazepam, Midazolam, Propofol, and Dexmedetomidine

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92
Q

Zero Order kinetic drugs are eliminated at a certain _ per hour and examples of this would be _ and _.

A

amount
alcohol and dilantin

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93
Q

First Order kinetic drugs are eliminated from the body at a certain _ per hour.

A

rate

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94
Q

The reason pts go to sleep so fast with propofol is due to _ _ of the drug from the blood to the brain and the reason they wake up so fast is because of _ _ from the brain to vital organs, muscle, and fat.

A

rapid DISTRIBUTION
rapid REDISTRIBUTION

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95
Q

A drug’s protein binding of _% or more is considered significant

A

90%

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96
Q

Acidic drugs primarily bind to _ and basic drugs primarily bind to _ _ _ _ in the plasma.

A

Albumin
Alpha 2 Acid Glycoprotein

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97
Q

T/F When more than one heavily protein bound drug is given together they will compete for receptors and cause one of the drug’s blood level to increase.

A

False, they DO compete but BOTH drugs blood levels will increase

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98
Q

If a drug is 99% protein bound and the free fraction is 1% and the free fraction is the active drug, and it enters a more protein deficient body where only 97% of it binds to protein, the active unbound drug is _ % higher than intended.

A

300%

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99
Q

Pts at risk for protein deficiency:

A

Malnutrition
Severe CKD
Severe liver disease
Last Tri Pregnancy

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100
Q

Most IV anesthetics’ mechanism of action is __ and they _ chloride ion flow into the cell causing it to become _.

A

GABA-mimetic
increase
hyperpolarized

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101
Q

Ketamine’s mechanism of action is that it acts as a _ _ on _ receptors.

A

Glutamate (Excitatory) Antagonist
NMDA receptors

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102
Q

Dexmedetomidine’s mechanism of action is that it is an highly selective alpha 2 adrenergic receptor _ and is _ and _ the release of catecholamines and acting on the alpha 2 _.

A

Alpha 2 Adrenergic Receptor AGONIST
sympathoLYTIC
decreases
autoreceptor

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103
Q

One of the major disadvantages within scope of anesthesia with benzos are their _ being longer than other drugs

A

half lives

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104
Q

Benzos are indicated for: (list a few indications)

A

sleep aid
anxiety
sedation
induction and/or maintenance of anesthesia

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105
Q

What is the brand name for Flumazenil and what class of drugs does it reverse?

A

Romazicon
benzos

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106
Q

Shorter acting benzos used for sleep aid:

A

Zolpidem (Ambien)
Zaleplon (Sonata)
Eszoplicone (Lunesta)

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107
Q

Non-benzo sleep aid with anesthesia implications:

A

Dual Orexin Receptor Antagonists (DORAs) -> Almorexant (Restora)
block orexin receptors which are involved in emergence “wake up”

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108
Q

IV induction drugs that cause pain on injection:

A

Diazepam **
Lorazepam *
Etomidate **
Propofol (both formulations) **

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109
Q

Which IV induction benzo drug does NOT cause pain on injection?

A

Midazolam (Versed)

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110
Q

Which 3 IV induction drugs’ solutions are water soluble?

A

Midazolam
Ketamine
Dexmedetomidine

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111
Q

Which IV induction drug should be avoided in asthmatics due to its sulfite component?

A

Generic formulation of propofol
-Diprivan formulation should be ok despite eggs, soy, and glycerol components

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112
Q

Which 3 IV induction drugs are considered excitatory?

A

Etomidate ***
Propofol *
Ketamine **

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113
Q

Which IV induction drugs are classified as analgesic?

A

Ketamine
Dexmedetomidine

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114
Q

Which IV induction drugs have the quickest onset?

A

Etomidate <30sec
Propofol <30sec
Midazolam 30-60sec
~Ketamine 45-60sec

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115
Q

Which IV induction drug has the longest onset of action?

A

Dexmedetomidine 2-5min

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116
Q

Which IV induction drug have the shortest durations?

A

Etomidate 5-10min
Propofol 3-8min

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117
Q

Which IV induction drug has the longest duration?

A

Lorazepam (60-120min)

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118
Q

GABA-mimetic agents possess _ and _ mechanisms

A

antiseizure
neuroprotective

119
Q

Retrograde amnesia:

A

erases previous memory

120
Q

Anterograde amnesia:

A

erase future memory
-used during anesthesia

121
Q

_ are the best drug class typically for IV induction because they cover sedation, anxiolysis, amnesia with minimal side effects.

A

Benzos -mainly midazolam

122
Q

Order of IV admin for induction:

A

Propofol (most cardiac and respiratory depressive)
Less propofol
Etomidate (less cardiac and respiratory depressive)
Ketamine (give in shock, NO cardiac or respiratory depression)

123
Q

The ONLY IV induction drug that is a bronchodilator and maintains reflexes (after initial apnea from injection) is _

A

ketamine

124
Q

A pt experiencing an asthma attack is hypotensive and needs to be intubated for an emergent surgery. Which IV induction drug would be ideal?

A

Ketamine

125
Q

Which IV induction drug inhibits BOTH autoregulation and CO2 reactivity?

A

Dexmedetomidine

126
Q

Which inhaled anesthetic inhibits autoregulation?

A

N2O

127
Q

Which IV induction drug is the only drug to excite the CNS?

A

Ketamine

128
Q

In terms of the cardiovascular effect, Ketamine will raise:

A

MAP
HR
CO
Venous Dilation

129
Q

In terms of the cardiovascular effects, Propofol will lower:

A

MAP
HR
CO
SVR
-it will INCREASE venous dilation

130
Q

Lorazepam and midazolam have no effect on _ but they cause venous dilation which can lead to _ _.

A

MAP
orthostatic (postural) hypotension

131
Q

Etomidate can induce _ _ in porphyria patients, leading to a porphyria attack from _ hemoglobin

A

ALA synthetase
excess

132
Q

Porphyria attacks can be brought on by _, _, _, _, and _.
(2 are induction IV drugs)

A

etomidate
toradol
propofol
CCBs
amiodarone

133
Q

Etomidate suppresses _ _ _, which helps body synthesize cortisol and aldosterone needed to tolerate stressors, and should especially be avoided in _ ill patients

A

11 beta hydroxylase
critically

134
Q

Propofol Infusion Syndrome can occur over _ hrs of a propofol infusion, causing severe _ acidosis, refractory _ failure, persistent and refractory _ , _, and _ and _ disturbances

A

48
metabolic
heart
bradycardia
fever
renal and heptatic

135
Q

Which IV induction drug is a phencyclidine derivative (LSD) and causes dissociative anesthesia?

A

Ketamine

136
Q

Ketamine can cause _ and _ IOP.

A

nystagmus
increased

137
Q

Ketamine _ salivation and secretions.

A

increases

138
Q

Ketamine _ muscle tone.

A

increases

139
Q

Ketamine should be cautiously used in pts with:

A

HTN, angina, CHF, increased ICP and IOP, psychological conditions, airway problems

140
Q

Ketamine can cause _ and _ which can be disturbing to patients and their familes.

A

hallucinations and delerium

141
Q

Ketamine is ideal for pts experiencing:

A

severe dehydration
shock
bronchospasm
severe anemia
one-lung anesthesia

142
Q

On emergence, pts who received Etomidate may experience _ hangover sensation and _ risk for emesis.

A

mild
high

143
Q

On emergence, pts who received Ketamine can experience _ and _ , and _ risk for emesis.

A

hallucinations and delirium
moderate/high

144
Q

On emergence, pts who received Propofol can experience _ hangover effect, _, and _ risk for emesis.

A

mild
euphoria
low

145
Q

Of the IV induction drugs _ is considered anti-emetic.

A

propofol

146
Q

The 3 IV induction drugs most likely to cause emesis on emergence are:

A

Etomidate *
Opioids
Ketamine*

147
Q

Which IV induction agent can cause myoclonus and hiccups after injection?

A

Etomidate

148
Q

Which IV induction drug causes the most severe recovery restlessness and PONV?

A

Ketamine

149
Q

Which IV induction drug has many routes of administration (ROA) making it great for use in kids?
-think Nagelhout peds dentist case example

A

Ketamine
-IV, IM, PO, liquid syrup mix, lollipop, etc.

150
Q

Along with dexmedetomidine, what drug is a highly selective alpha 2 adrenergic receptor agonist?

A

catapres/ clonidine

151
Q

Which IV anesthetic causes lighter sedation and easier arousal?

A

Dexmedetomidine

152
Q

Dexmedetomidine is highly _ and highly bound to plasma proteins

A

lipophilic

153
Q

Which IV anesthetic can be useful for postop shivering?

A

Dexmedetomidine
Merperidine (Demerol)

154
Q

Dexmedetomidine reduces sympathetic outflow by reducing release of _

A

norepinephrine

155
Q

Dexmedetomidine causes increased cardiac vagal activity with alpha 2 antagonism of the dorsal motor nucleus at _ doses by causing _ outflow.

A

lower
parasympathomimetic

156
Q

Dexmedetomidine is _ compared to other IV anesthetics.

A

expensive

157
Q

Dexmedetomidine’s cardiac side effects include _ and _.

A

bradycardia and hypotension

158
Q

Droperidol (Butyrophenone) is a tranquilizer that blocks _ receptors to prevent emesis

A

dopamine

159
Q

Droperidol has a black box warning for _ _

A

QT prolongation

160
Q

T/F IV anesthetics have faster emergence than inhaled anesthetics

A

false

161
Q

Barbiturates involve _ and _ GABA inhibitory pathways leading to loss of consciousness and respiratory and cardiac depression

A

cortical and brainstem

162
Q

Which IV anesthetic is used for amnesia and conscious sedation?

A

Midazolam

163
Q

Which IV anesthetic’s sympathomimetic effects completely preserve cardiac function?

A

Ketamine

164
Q

Which IV anesthetic causes inhibition of adrenocortical synthesis?

A

Etomidate

165
Q

Which IV anesthetic has both parasympathomimetic and sympatholytic properties that cause dose dependent decrease in HR and CO?

A

Dexmedetomidine

166
Q

T/F flumazenil has a longer half life than the benzos it typically reverses and will be adequate even for Valium.

A

False
-half life is shorter than benzos typically and will sometimes need more than one dose o a continuous infusion to reverse pt again after initial dose wears off (esp. with Valium).

167
Q

Which benzo is in acid form in its vial, then changes shape and transitions from pro-drug to active drug in the plasma pH?

A

Midazolam

168
Q

Speed of recovery is inversely proportional to _

A

solubility (B/G)

169
Q

The most expensive inhaled anesthetic is _

A

Sevo

170
Q

Sevo is used mainly in cases with _ patients, _ patients, _ surgery, or cases < _ in duration

A

obese
pediatric
ambulatory
1hr

171
Q

If hospital short on propofol, can give _ instead as they work interchangeably except for its ability to suppress seizures.

A

Methohexital

172
Q

ECT cases:
-induction
-NMB

A

Induction: Methohexital, Propofol, Thiopental, Etomidate, Ketamine, Benzos, Sevo
NMB: Succinylcholine, Mivacurium, Atracurium, Rocuronium, Rapacurium

173
Q

When using thiopental for ECT, it has the cardiac effect of increased _ and _s

A

bradycardia and PVCs

174
Q

When using Etomidate for ECT, it causes _ seizure duration, _ recovery from post-ECT confusion and _ N/V compared to other drugs.

A

longer
delayed
more

175
Q

When using Ketamine for ECT, it can cause _ ICP leading to less than desirable _ properties.

A

increased
analgesic

176
Q

Drug of choice in ECT is _ because it is an ultra short barbiturate and cleared rapidly.

A

Methohexital

177
Q

2nd drug of choice in ECT is _ because of its rapid emergence and elimination, but it can increase the risk of a missed seizure.

A

propofol

178
Q

Haloperidol is in the butyrophenone class and if given in low doses has a high affinity for _ receptors and can produce an _ effect.

A

dopamine (D2)
antiemetic

179
Q

Haldol, like Droperidol, has the negative cardiac effect of _ _.

A

QT prolongation

180
Q

Which of the benzos are highly protein bound and problematic for elderly patients?

A

Diazepam

181
Q

The inhaled anesthetic that offers the best bronchodilator properties is _

A

Sevoflurane

182
Q

The inhaled anesthetic that lasts long and is ideal for cases with patients who will be intubated following the procedure is _

A

Isoflurane

183
Q

MH is also called:

A

Neuroleptic Malignant Syndrome
Serotonin Syndrome

184
Q

Symptoms of MH include:

A

muscle rigidity ***
EtCO2 increase (50-80)
Tachycardic
Tachypneic
High BP
Hyperkalemia

185
Q

MH treatment drugs:

A

Methylene Blue or Dantrolene
Fluids (not LR)
K Cocktail
Albuterol
Kayexalate
hyperventilation

186
Q

Don’t use flows less than _ L/min of Sevo because it causes _

A

2L/min
hypoxemia

187
Q

3 chemicals in body used for analgesia:

A

Enkephalins
Endorphins
Dynorphins

188
Q

3 greek named opioid receptors (ORL1 receptor)

A

Mu
Delta
Kappa

189
Q

When opiate receptors on the _-synaptic neuron are _, it prevents the release of Substance P, inhibiting the pain signal.

A

PRE-synaptic
ACTIVATED

190
Q

Opioid mechanism of action: once ligand or drug bind to receptor, activates the -, causing multiple effects that are primarily _. The activity of adenylyl cyclase and voltage dependent CA++ is _.

A

G-protein
inhibitory
depressed

191
Q

3 factors about Opiate drugs that always are associated (due to the mu receptor):

A

Potency
Amount of Resp. Depression
Addiction Liability

192
Q

Mu receptor effects:

A

Analgesia (supra/spinal)
EUPHORIA/sedation
physical dependence
resp. depression
miosis
constipation - major
urine rtn
bradycardia
itch
skel musc. rigidity
biliary spasm
-there’s a lot!!!

193
Q

Mu receptor:
-agonist
-antagonist

A

Agonist: endorphins, morphine, synthetic opioids

Antagonist: Naltrexone, Naloxone, and Nalmefene

194
Q

Kappa Receptor effects:

A

Analgesia (supra/spinal)
DYSPHORIA/sedation
low abuse potential
miosis
ANTISHIVERING

195
Q

Kappa receptor:
-agonist
-antagonist

A

Agonist: Dynorphins

Antagonist: Naloxone, Naltrexone, Nalmefene

196
Q

Delta receptor effects:

A

Analgesia (supra/spinal)
Physical dependence
resp. depression
constipation - minor
urine rtn

197
Q

Delta
-agonist
-antagonist

A

Agonist: Enkephalins

Antagonist: Naloxone, Naltrexone, Nalmefene

198
Q

Most opioid effects occur on the _ receptor

A

Mu

199
Q

Which 2 opioid receptors cause physical dependence?

A

Mu and Delta
-Kappa has least abuse potential

200
Q

What do each opioid receptor have in common?

A

Common effect of analgesia at the spinal and supraspinal level
Same antagonists

201
Q

Which opioid receptor has anti-shivering and dysphoric effects?

A

Kappa receptor

202
Q

Most common way to classify opioids:

A

chemical structure

203
Q

T/F If a pt is allergic to an opioid, they will be allergic to all opioids regardless of subclass.

A

false, pt will be allergic to all other drugs in that class most likely

204
Q

Asthma patients should avoid opioid classes that have a histamine release effect such as _ and _. The _ subclass should be safe, however.

A

Phenanthrenes and Demerol
Phenylperidines

205
Q

Other than chemical structure, opioids have subclasses that are classified by their _.

A

efficacy
-full agonist, partial agonist (has a ceiling effect), antagonist, etc.

206
Q

Phenanthrene Alkaloid Naturally Occurring Agonists:

A

Morphine
Codeine
Thebaine

207
Q

Phenanthrene Alkaloid Semisynthetic Agonists:

A

Diacetylmorphine (Heroin)
Hydrocodone (Vicodin)
Hydromorphone (Dilaudid)
Oxycodone (Oxycontin)
Tramadol
Naltrexone
Naloxone
Nalmefene
-**most common

208
Q

Phenanthrene Alkaloid Synthetic Agonists:
-morphine derivatives
-benzmorphans

A

Morphine derivatives:
Levorphanol
Butorphanol
Nalbuphine

Benzmorphan:
Pentazocine

209
Q

What is the most common subclass of opiates used?

A

Phenanthrene Alkaloid Semisynthetic Agonists

210
Q

Peridine Derivative Agonists (synthetic)- Phenylpiperidines:

A

Meperidine (Demerol)
Loperamide

211
Q

Peridine Derivative Agonists (synthetic)- 4-Anilidopiperidines:

A

Fentanyl
Sufentanyl
Alfentanyl
Remifentanyl

212
Q

Diphenylheptane (synthetic methadone derivative) Agonists:

A

Methadone

213
Q

Subclasses of Opioids (based on chem structure):

A

Phenanthrenes (natural, semisynth, synthetic-morphine and benzmorphan derviatives)
Piperidine Derivatives (Phenylpiperidines and 4-Anilidopiperidines)
Diphenyheptanes (methadone derivatives)

214
Q

T/F Someone allergic to fentanyl will also be allergic to Meperidine

A

true

215
Q

T/F Someone allergic to codeine can have oxycodone because they’re in different classes

A

false, they’re under the same umbrella of phenanthrene alkaloids

216
Q

The potency of opioids is variable due to the _ _ associated with pain

A

emotional response

217
Q

The opiate with the highest potency ratio is _

A

Sufentanyl

218
Q

The opiate with the weakest potency ratio is _

A

Codeine

219
Q

Fentanyl is in which subclass of opioids?

A

Piperidine Derivatives- 4-Anilidoperidine

220
Q

Hydromorphone is in which subclass of opioids?

A

Phenanthrene Alkaloids-semisynthetic

221
Q

Methadone is in which subclass of opioids?

A

Diphenylheptanes

222
Q

Naltrexone is in which subclass of opioids?

A

Phenanthrene Alkaloids-semisynthetic

223
Q

Why could demerol and codeine be harmful to asthmatics?

A

Release histamines

224
Q

T/F If a pt has liver disease you can expect pt to need higher doses of opioids to work and last longer.

A

False, their disease will make meds last longer and they will require smaller doses

225
Q

Remifentanyl is metabolized by - _ enzymes via _.

A

non-specific esterase
hydrolysis

226
Q

Remifentanyl lasts about _ minutes and must be given as an infusion with another med ready to give when pt wakes up.

A

5 mins

227
Q

The 3 most highly protein bound opiates are:

A

Sufentanyl
Alfentanyl
Methadone

228
Q

The opiate with the smallest volume of distribution is _.

A

Remifentanyl ( hardly leaves the plasma bc so water soluble)
~0.3-0.4L/kg

229
Q

Which opiate has the longest elimination half life?

A

Methadone ~15-20hrs

230
Q

Which opiate has the shortest elimination half life?

A

Remifentanyl 0.1-0.2hrs

231
Q

Which opiate has the shortest duration?

A

Remifentanyl ~2-5mins

232
Q

It’s better to - opiates during a case.

A

front-load

233
Q

Acute effects of opiates:

A

analgesia
resp. depression
sedation
euphoria
vasodilation
bradycardia
cough suppression
miosis
N/V
skel. musc. rigidity
smooth musc. spasm
constipation
urine rtn
biliary spasm
itch
antishivering (meperidine only)
-a lot!

234
Q

Chronic effects of opiates:

A

tolerance
physical dependence
constipation

235
Q

Which subclass of opiates can cause postural hypotension/ orthostatic hypotension?

A

histamine-releasing opiates: Phenanthrenes and demerol!

236
Q

Every time an opiate is given to a pt, their _ will increase.

A

CO2
-eventually pt will stop breathing

237
Q

At end of case, if pt not breathing and CO2 is at or above _ mmHg, either call APCU for a vent or give _.

A

50mmHg
Narcan

238
Q

Pt’s can’t develop a tolerance for _ and _ in opiates

A

miosis and constipation

239
Q

Which drug class can suppress cough which helps with tolerating ETT and emergence?

A

opiates

240
Q

Pupils constrict with opiates due to a _ or _ effect.

A

parasympathomimetic or vagal

241
Q

The vomiting center receives input from the chemotactic trigger zone via the _ _

A

vagus nerve

242
Q

The _ _ _ (_) is an area in postrema of brain that senses the O2 level in blood and causes N/V.

A

chemotactic trigger zone
CTZ

243
Q

Anyone who receives a _ is at higher risk for N/V and this typically occurs _ because eventually drug has an inhibiting effect on the _ _ _

A

narcotic
initially
CTZ chemotactic trigger zone

244
Q

Narcotics are resp. depressors because they shift the CO2 response curve to the _, meaning it takes a _ CO2 to drive up respirations

A

right
higher

245
Q

PONV risk factos:

A

female
<50yo
hx PONV (#1)
high dose intra/postop opiates
surg > 1hr
laproscopic procedures`

246
Q

PDNV risk factors:

A

female
<50 yo
hx PONV
PONV in PACU

247
Q

Best prophylaxis/treatment for PONV:

A

multimodal antiemetic therapy

248
Q

Things that stimulate CTZ which then stimulates vomit center:

A

Opioids (initially)
Vestibular part of CN VIII

249
Q

Things that inhibit CTZ and therefore inhibit vomit center:

A

Benzos/Propofol
Dopamine ANTAgonists
Serotonin ANTAgonists
Histamine ANTAgonists
Acetylcholine (muscarinic) ANTAgonists
Opioids (after initial dose)

250
Q

Most widely used/gold standard antiemetic:

A

Ondansetron (Zofran)

251
Q

Preferred drug for PDNV:

A

Palonosetron (Axoli)

252
Q

Drug classes indicated for PONV:

A

Glucocorticoids
5HT3 Receptor Antagonists
Neurokinin 1 Receptor Antagonists
Antihistamines
Transdermal Scopolamine(anticholinergic)
+Metoclopramide(Reglan)

253
Q

Dexamethasone (and methylprednisolone) for PONV should be given _ induction and _ surgery

A

after
before

254
Q

Dexamethasone is thought to act as a _ antagonist on the CTZ

A

serotonin

255
Q

A diabetic pt is at risk for PONV, which antiemetic drug class should be avoided in this population? Why?

A

glucocorticoids
-spikes BG for 6-12 hrs following admin, not nice

256
Q

What negative effect could come with using dexamethasone or methylprednisolone for PONV?

A

can mask infection, delay wound healing :(

257
Q

Your pt with a hx of 2nd degree type 2 block and LBBB is complaining of nausea prior to a case. Which antiemetic drug class should be avoided if possible and why?

A

5-HT3 Receptor Antagonists like Zofran
-prolongs QT interval leading to torsades

258
Q

Which antiemetic can lead to serotonin syndrome with concurrent use with zofran?

A

Palonosetron for PDNV

259
Q

What time is zofran typically given for a case?

A

beginning
-works better with dexamethasone added

260
Q

How does Emend work as an antiemetic?

A

Substance P/ neurokinin1 antagonist
-suppresses activity at nucleus of solitary tract where vagal afferents from GI system interact with inputs from area postrema to the brain that initiate vomiting

261
Q

Droperidol was used for decades as an antiemetic as a _ receptor blocker in the CNS, making it awful for pts with _ disease by causing EPS. It also has a black box warning for what?

A

dopamine
Parkinson’s
QT prolongation

262
Q

Transdermal Scopolamine blocks _ impulses from the vestibular nuclei to high centers in the CNS. Due to its longer onset, when should it be applied for PONV prophylaxis?

A

cholinergic
Evening prior to case

263
Q

Scopolamine patches are a great antiemetic for _ due to their effect on the vestibular nuclei but come with side effect including _, _ _, _, and _ _.

A

motion sickness
dizziness, dry mouth, sedation, blurred vision
-sounds like a bummer on a cruise tbh

264
Q

Midazolam can be used prophylactically for PONV as a _ inhibitor on the CTZ but should be given _ or _.

A

dopamine
pre/intraoperatively

265
Q

Metoclopramide (Reglan) is a weak _ blocker but can cause _ in high doses and has a _ half life

A

dopamine
dyskinesia/ EPS
short (30-40 mins)
- i get why pt were pissed with this drug, Tigan works better tbh

266
Q

If PONV occurs within _ hrs postop, do not give the same medication class given prophylactically, use one from another class with another admin method

A

6

267
Q

Common 5-HT3 Antagonists used for antiemetics:

A

Ondansetron (Zofran)**
Granisetron (Kytril)
Palonosetron (Aloxi) **

268
Q

Common Dopamine Antagonists used for antiemetics:

A

Droperidol (Inapsine)**
Haloperidol (Haldol)**
Metoclopramide (Reglan)
Prochlorperizine (Compazine)

269
Q

Common Antihistamines used for antiemetics:

A

Hydroxazine (Atarax)
Promethazine (Phenergan)
Diphenhydramine (Benadryl)

270
Q

Common Glucocorticoids used for antiemetics:

A

Dexamethasone (Decadron)
Methylprednisolone (Prednisone)

271
Q

Common Anticholinergic used for antiemetics:

A

Scopolamine transdermal

272
Q

Common Neurokinin-1 Antagonists used for antiemetics:

A

Aprepitant (Emend)
Rolapitant (Varubi)

273
Q

Giving a narcotic too quickly or at a high dose can cause _ _ rigidity AKA _ _, which is treated with a _ _

A

chest wall rigidity
tight chest
muscle relaxant
-pt can’t be ventilated, too tight

274
Q

Narcotics have a vagal effect in the sphincter of Oddi in the bile duct causing it to contract, bad if in a choli-angiogram case, give 4 things:

A

Atropine or glycopyrolate
give SL NTG
give glucagon
give naloxone

275
Q

To treat epidural-morphine induced pruritis, give _

A

ondansetron

276
Q

To prevent pruritis, you can give 3 different meds:
(follow hosp policy tho)

A

Droperidol
Propofol
Alizapride

277
Q

_ can be given for antishivering properties and it works on the _ opioid receptors

A

Merperidine (Demerol)
KAPPA

278
Q

Fentanyl comes in many routes of administration:

A

transdermal or iontophoretic transdermal
oral transmucosal (lollipops/tablets)
intranasal
transpulmonary

279
Q

Tramadol is metabolized into the _ metabolite which is 6x as potent than its parent compound and is metabolized by the _ enzyme

A

M1
CYP3D6

280
Q

Hydrocodone has varying effectiveness from genetic status of parents affecting the _ receptor binding and is metabolized by the _ enzyme

A

mu
CYP3D6

281
Q

Oxycodone has significant _ and effectiveness depending on the metabolic genotype and is metabolized by the _ enzyme

A

VARYING
CYP3D6

282
Q

Codeine is a _ and is metabolized into its active form, morphine and is metabolized by the _ enzyme

A

prodrug
CYP3D6

283
Q

CYP3A4 enzyme metabolizes _, _, and _ in varying fashion depending on the enzymatic activity.

A

fentanyl
buprenorphine
methadone

284
Q

CYP3B6 metabolizes _ and _ and women typically have higher levels of enzyme activity

A

propofol
methadone

285
Q

Opioid antagonists (brand names too):

A

Naloxone (Narcan)
Naltrexone (Trexane, Vivitrol NT-ER)
Nalmefene (Revex)

286
Q

Narcan titration:

A

use 5ml syringe,
draw up the 1ml from the 0.4mg/ml vial
draw up 3ml sterile water
now you have 4ml total with 0.1mg/ml and you can “titrate” it

287
Q

Tell PACU RN if you gave narcan and that you are concerned with pt _

A

re-narcotizing

288
Q

Naltrexone (Vivitrol NT-ER) is used to help alcoholics trying to quit, so may need to give these pts _ narcotics during a case bc drugs will have to _ for receptor sites

A

more
compete

289
Q

What are the preferred endogenous ligands for mu receptors:

A

beta endorphins
met- and leu- enkephalins

290
Q

What are the preferred endogenous ligands for the delta receptor?

A

met and leu enkephalins

291
Q

What are the preferred endogenous ligands for the kappa receptor?

A

dynorphins

292
Q

What is the preferred endogenous ligand for the ORL1 receptor?

A

nociceptin

293
Q

Droperidol (Inapsine)
-class
-use
-extra info

A

dopamine blocking antiemetic
-black box warning for QT prolongation (used to be given)

294
Q

Merperidine (Demerol)
-class
-use
-extra info

A

phenylpiperidine opiate
anti shivering, weaker than morphine,works on KAPPA receptor

Advanced Pharm For NA 1 (4 decks)

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