Exam 2 Study Guide Flashcards
1
Q
Sevoflurane (Ultane)
-MAC %
-B/G Partition Coefficient
-O/G Partition Coefficient
A
2%
0.6
50 -potent
2
Q
Isoflurane (Forane)
-MAC %
-B/G Partition Coefficient
-O/G Partition Coefficient
A
1.15%
1.4
99 -very potent
3
Q
Nitrous Oxide
-MAC%
-B/G Partition Coefficient
-O/G Partition Coefficient
A
105%
0.47
1.4 -not potent at all
4
Q
Desflurane (Suprane)
-MAC%
-B/G Partition Coeffficient
-O/G Partition Coefficient
A
5.8%
0.42
18.7 -not very potent
5
Q
Halothane (Fluothane)
-MAC%
-B/G Partition Coefficient
-O/G Partition Coefficient
A
0.75%
2.3
224 -very potent
6
Q
MAC and potency is _ proportional
A
inversely
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
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
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
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
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
12
Q
The only inorganic anesthetic gas is _
A
Nitrous oxide (no carbon group)
13
Q
Amnesia is the loss of memory and acts on the _ and _
A
hippocampus
amygdala
14
Q
Unconsciousness is controlled through the _, _, and _.
A
cortex
thalamus
brainstem
15
Q
Analgesia is the loss of pain and occurs through the _ _
A
spinothalamic tract
16
Q
Immobility is the loss of motor control and occurs thru the _ _ and the _ _ _
A
spinal cord
central pattern generators
17
Q
CNS effects of anesthesia are _ -dependent with _ requiring the lowest dose (MAC) followed by sedation, unconsciousness, and immobility.
A
dose dependent
amnesia
18
Q
In general, CNS and ANS are _ with volatile anesthetics
A
depressed
19
Q
T/F Volatile anesthetics are cerebral-protective with antioxidant effects that prevent damage to cells
A
True
20
Q
5 effects of anesthesia gases on neuological system
A
- ICP
- Autoregulation of CBF and cerebral reactivity to CO2
- Cerebral metabolic rate of O2 (CMRO2)
- CSF Pressure
- Neuro assessments (obviously)
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
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
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
24
Q
All inhaled anesthetics (and most IV anesthetics) will _ MEPs, but _ will do so the most.
A
decrease
Isoflurane
25
Almost all inhaled and IV anesthetics decrease SSEPs except _ and _ which increase them
Etomidate
Ketamine
26
Of the IV anesthetics, only _ increases CBF, CMRO2, ICP, SSEPs, and CPP/MAP
ketamine
27
Unlike the other inhaled anesthetics, _ doesn't have a large affect on CMRO2 and ICP
N2O
28
Increasing the dose of anesthetics will typically cause decreased BP EXCEPT in which 4 anesthetics(usually)?
N20
Ketamine
Etomidate
Precedex
29
The 5 factors that cause BP to fall during anesthesia are:
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
30
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.
1:100,000 ~ 0.01mg/mL
10mL (0.1mg)
30mL (0.3mg)
-volume administered can be adjusted by changing concentration of the dose
31
Which (main) inhaled anesthetic can cause tachycardia due to respiratory irritation and what is a first line intervention for this?
Desflurane
Fentanyl IV
32
The inhaled anesthetics all lower MAP and SVR EXCEPT
N2O
-can increase SVR, no effect on MAP
33
The inhaled anesthetics all increase HR EXCEPT
Sevoflurane
34
Which 2 inhaled anesthetics are known to lower CO?
Isoflurane and N2O
35
All inhaled anesthetics bronchodilate and cause dose dependent respiratory depression EXCEPT
N2O
36
Which 2 inhaled anesthetics are respiratory irritants?
Desflurane and Isoflurane
37
Unlike opiates, the respiratory depressant nature of inhaled anesthetics (except N2O) causes _ to decrease before _.
Vt
RR
38
All inhaled anesthetics (besides N2O) decrease _, which decreases renal _ _, decreasing _, which then will cause decreased _
BP
renal blood flow
GFR
UOP
39
Which inhaled anesthetic has the highest rate of toxic metabolites?
Sevoflurane 5-8%
-don't give to renal pts
-lasts longer in obese pts
40
Which inhaled anesthetic is known to cause hepatotoxicity?
Halothane
41
Which inhaled anesthetics can trigger MH and therefore are contraindicated in pts at risk?
ALL EXCEPT N2O
-Succinylcholine too!
42
N2O oxidizes the cobalt atom on _ _, inhibiting _ _ which disrupts DNA/RNA synthesis.
Vitamin B 12
Methionine Synthetase
43
Which inhaled anesthetic can cause immunosuppression in at risk pts?
N2O
44
What are 3 absolute contraindications for giving N2O?
- 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)
45
CO2 absorbers can get dry and produce _ during a case if the machine hasn't been used in a while
CO
46
In regards to CO2 absorbers, Compound A can form when "low flow _" is given usually at flow rates < _L/min
low flow Sevo
<2L/min
-newer CO2 absorbers don't react with Sevo
47
Which anesthetics/OR drugs can worsen cancer/ risks?
Volatile anesthetics
Opiates
Supplemental O2
48
Which 3 anesthetics are helpful against cancer risks/growth?
Local Anesthetics
NSAIDs
Propofol
49
The only inhaled anesthetic proven as teratogenic is _ and it is contraindicated in pregnancy (not delivery) due to its risk for spontaneous abortion
N2O
50
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)
7
boggy
51
Kids between the ages of _ _ and _ years of age can experience neurotoxicity from inhaled anesthetics and should have cases kept short if possible.
third trimester
3yo
52
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.)
sevoflurane
desflurane
53
Female CRNAs can experience higher likelihood of miscarriage or birth defects when exposed to cases involving: (3 items)
1. N2O
2. Xray imaging (ortho cases)
3. peds cases (mask induction often)
54
Male CRNAs are more likely to produce children who are _.
female
55
T/F Inhaled anesthetics don't pass the placental-fetal barrier.
false, they ALL do
56
Non-urgent surgeries should occur during the _ trimester in pregnant women.
2nd
57
Most IV anesthetics (EXCEPT _) pose significant neurodevelopmental risk.
precedex
58
GA during emergent CS has no association with learning disability but it does with _.
Autism
59
In addition to N2O, two main drug classes that are considered teratogenic are:
Anticonvulsants and Antipsychotics
60
If given close to delivery, sedatives and hypnotics can cause _ _ in the newborn.
respiratory depression
61
Exposure to opioids in early pregnancy can cause congenital _ _
heart defects
62
T/F Muscle relaxants can cross the placental barrier.
False
63
NAIDs are contraindicated during pregnancy and have different negative outcomes for different trimesters:
1.
2.
3.
1.spontaneous abortion
2.congenital cryptoracism
3. renal injury and constriction of ductus arteriosus
64
The vasopressor of choice for pregnant patients is _
Ephedrine
65
Ionizing radiation is considered teratogenic and can cause _ _ thru gestational weeks 8-15 and childhood _
mental retardation
leukemia :(
66
T/F Heparin and Abx are ok in pregnancy
true
67
T/F quinolone, tetracycline, and codeine are ok in pregnancy
false
68
Age of viability of a fetus:
24 wks
69
Fast recovery of anesthesia is _ proportional to the solubility of the med
inversely
70
T/F A longer case will cause a longer emergence
true
71
Which inhaled anesthetic can cause seizure on EEG?
Sevoflurane = Seizurflurane
72
MAC peaks at _ months old
6
73
Sevo
-Boiling point
-Vapor Pressure
58*C
157
74
Des
-boiling point
-vapor pressure
24*C
669
75
Iso
-boiling point
-vapor pressure
49*C
238
76
N2O
-boiling point
-vapor pressure
-88*C
38,770
77
Which inhaled anesthetic boils at room temp and is easiest to vaporize?
Desflurane
-vapor pressure is close to 760
78
It takes _ half lives to get rid of a drug.
4
79
How much of a drug is gone after 3 half lives?
87.5% is gone
12.5% is left
80
Common drugs in benzo class:
diazepam (vallium)
lorazepam (ativan)
midazolam (versed)
flumazenil (romazicon)
81
Common drug in butyrophynone class:
Droperidol (Inapsine)
82
Common induction drugs in miscellaneous classes:
Propofol (Diprivan)
Etomidate (Amidate)
Ketamine (Ketalar)
Dexmedetomidine (Precedex)
83
Common drugs in barbiturate class:
Thiopental (Petothal)
Metohexital (Brevital)
Phenobarbital (Luminal)
Pentobarbital
Secobarbital
84
Alpha half life is how long it takes from drug to go from _ to _ and is due to drug _
blood to tissue
distribution
85
Beta half life is how long drug takes after distribution to be 50% _ and is due to drug _.
eliminated
metabolism
86
_ of _ is a number that indicates how widely a drug is distributed in the body
Volume of Distribution (Vd)
87
Normal Vd for a 70kg pt is about _L or _L/kg
42L or 0.6L/kg
88
A smaller Vd (<0.4L/kg) means the drug is mainly contained in the _ and is _ solube
plasma
water
89
A larger Vd (>0.6L/kg) means the drug is mainly contained in the _ and is _ soluble
body
lipid
90
_ has the longest elimination half life out of the IV anesthetics at 20-50hrs.
Diazepam (Valium)
91
Common heavily (>90%) protein bound IV anesthetics include: (5 items)
Diazepam, Lorazepam, Midazolam, Propofol, and Dexmedetomidine
92
Zero Order kinetic drugs are eliminated at a certain _ per hour and examples of this would be _ and _.
amount
alcohol and dilantin
93
First Order kinetic drugs are eliminated from the body at a certain _ per hour.
rate
94
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.
rapid DISTRIBUTION
rapid REDISTRIBUTION
95
A drug's protein binding of _% or more is considered significant
90%
96
Acidic drugs primarily bind to _ and basic drugs primarily bind to _ _ _ _ in the plasma.
Albumin
Alpha 2 Acid Glycoprotein
97
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.
False, they DO compete but BOTH drugs blood levels will increase
98
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.
300%
99
Pts at risk for protein deficiency:
Malnutrition
Severe CKD
Severe liver disease
Last Tri Pregnancy
100
Most IV anesthetics' mechanism of action is __ and they _ chloride ion flow into the cell causing it to become _.
GABA-mimetic
increase
hyperpolarized
101
Ketamine's mechanism of action is that it acts as a _ _ on _ receptors.
Glutamate (Excitatory) Antagonist
NMDA receptors
102
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 _.
Alpha 2 Adrenergic Receptor AGONIST
sympathoLYTIC
decreases
autoreceptor
103
One of the major disadvantages within scope of anesthesia with benzos are their _ being longer than other drugs
half lives
104
Benzos are indicated for: (list a few indications)
sleep aid
anxiety
sedation
induction and/or maintenance of anesthesia
105
What is the brand name for Flumazenil and what class of drugs does it reverse?
Romazicon
benzos
106
Shorter acting benzos used for sleep aid:
Zolpidem (Ambien)
Zaleplon (Sonata)
Eszoplicone (Lunesta)
107
Non-benzo sleep aid with anesthesia implications:
Dual Orexin Receptor Antagonists (DORAs) -> Almorexant (Restora)
block orexin receptors which are involved in emergence "wake up"
108
IV induction drugs that cause pain on injection:
Diazepam ***
Lorazepam *
Etomidate ***
Propofol (both formulations) **
109
Which IV induction benzo drug does NOT cause pain on injection?
Midazolam (Versed)
110
Which 3 IV induction drugs' solutions are water soluble?
Midazolam
Ketamine
Dexmedetomidine
111
Which IV induction drug should be avoided in asthmatics due to its sulfite component?
Generic formulation of propofol
-Diprivan formulation should be ok despite eggs, soy, and glycerol components
112
Which 3 IV induction drugs are considered excitatory?
Etomidate ***
Propofol *
Ketamine **
113
Which IV induction drugs are classified as analgesic?
Ketamine
Dexmedetomidine
114
Which IV induction drugs have the quickest onset?
Etomidate <30sec
Propofol <30sec
Midazolam 30-60sec
~Ketamine 45-60sec
115
Which IV induction drug has the longest onset of action?
Dexmedetomidine 2-5min
116
Which IV induction drug have the shortest durations?
Etomidate 5-10min
Propofol 3-8min
117
Which IV induction drug has the longest duration?
Lorazepam (60-120min)
118
GABA-mimetic agents possess _ and _ mechanisms
antiseizure
neuroprotective
119
Retrograde amnesia:
erases previous memory
120
Anterograde amnesia:
erase future memory
-used during anesthesia
121
_ are the best drug class typically for IV induction because they cover sedation, anxiolysis, amnesia with minimal side effects.
Benzos -mainly midazolam
122
Order of IV admin for induction:
Propofol (most cardiac and respiratory depressive)
Less propofol
Etomidate (less cardiac and respiratory depressive)
Ketamine (give in shock, NO cardiac or respiratory depression)
123
The ONLY IV induction drug that is a bronchodilator and maintains reflexes (after initial apnea from injection) is _
ketamine
124
A pt experiencing an asthma attack is hypotensive and needs to be intubated for an emergent surgery. Which IV induction drug would be ideal?
Ketamine
125
Which IV induction drug inhibits BOTH autoregulation and CO2 reactivity?
Dexmedetomidine
126
Which inhaled anesthetic inhibits autoregulation?
N2O
127
Which IV induction drug is the only drug to excite the CNS?
Ketamine
128
In terms of the cardiovascular effect, Ketamine will raise:
MAP
HR
CO
Venous Dilation
129
In terms of the cardiovascular effects, Propofol will lower:
MAP
HR
CO
SVR
-it will INCREASE venous dilation
130
Lorazepam and midazolam have no effect on _ but they cause venous dilation which can lead to _ _.
MAP
orthostatic (postural) hypotension
131
Etomidate can induce _ _ in porphyria patients, leading to a porphyria attack from _ hemoglobin
ALA synthetase
excess
132
Porphyria attacks can be brought on by _, _, _, _, and _.
(2 are induction IV drugs)
etomidate
toradol
propofol
CCBs
amiodarone
133
Etomidate suppresses _ _ _, which helps body synthesize cortisol and aldosterone needed to tolerate stressors, and should especially be avoided in _ ill patients
11 beta hydroxylase
critically
134
Propofol Infusion Syndrome can occur over _ hrs of a propofol infusion, causing severe _ acidosis, refractory _ failure, persistent and refractory _ , _, and _ and _ disturbances
48
metabolic
heart
bradycardia
fever
renal and heptatic
135
Which IV induction drug is a phencyclidine derivative (LSD) and causes dissociative anesthesia?
Ketamine
136
Ketamine can cause _ and _ IOP.
nystagmus
increased
137
Ketamine _ salivation and secretions.
increases
138
Ketamine _ muscle tone.
increases
139
Ketamine should be cautiously used in pts with:
HTN, angina, CHF, increased ICP and IOP, psychological conditions, airway problems
140
Ketamine can cause _ and _ which can be disturbing to patients and their familes.
hallucinations and delerium
141
Ketamine is ideal for pts experiencing:
severe dehydration
shock
bronchospasm
severe anemia
one-lung anesthesia
142
On emergence, pts who received Etomidate may experience _ hangover sensation and _ risk for emesis.
mild
high
143
On emergence, pts who received Ketamine can experience _ and _ , and _ risk for emesis.
hallucinations and delirium
moderate/high
144
On emergence, pts who received Propofol can experience _ hangover effect, _, and _ risk for emesis.
mild
euphoria
low
145
Of the IV induction drugs _ is considered anti-emetic.
propofol
146
The 3 IV induction drugs most likely to cause emesis on emergence are:
Etomidate ***
Opioids**
Ketamine*
147
Which IV induction agent can cause myoclonus and hiccups after injection?
Etomidate
148
Which IV induction drug causes the most severe recovery restlessness and PONV?
Ketamine
149
Which IV induction drug has many routes of administration (ROA) making it great for use in kids?
-think Nagelhout peds dentist case example
Ketamine
-IV, IM, PO, liquid syrup mix, lollipop, etc.
150
Along with dexmedetomidine, what drug is a highly selective alpha 2 adrenergic receptor agonist?
catapres/ clonidine
151
Which IV anesthetic causes lighter sedation and easier arousal?
Dexmedetomidine
152
Dexmedetomidine is highly _ and highly bound to plasma proteins
lipophilic
153
Which IV anesthetic can be useful for postop shivering?
Dexmedetomidine
Merperidine (Demerol)
154
Dexmedetomidine reduces sympathetic outflow by reducing release of _
norepinephrine
155
Dexmedetomidine causes increased cardiac vagal activity with alpha 2 antagonism of the dorsal motor nucleus at _ doses by causing _ outflow.
lower
parasympathomimetic
156
Dexmedetomidine is _ compared to other IV anesthetics.
expensive
157
Dexmedetomidine's cardiac side effects include _ and _.
bradycardia and hypotension
158
Droperidol (Butyrophenone) is a tranquilizer that blocks _ receptors to prevent emesis
dopamine
159
Droperidol has a black box warning for _ _
QT prolongation
160
T/F IV anesthetics have faster emergence than inhaled anesthetics
false
161
Barbiturates involve _ and _ GABA inhibitory pathways leading to loss of consciousness and respiratory and cardiac depression
cortical and brainstem
162
Which IV anesthetic is used for amnesia and conscious sedation?
Midazolam
163
Which IV anesthetic's sympathomimetic effects completely preserve cardiac function?
Ketamine
164
Which IV anesthetic causes inhibition of adrenocortical synthesis?
Etomidate
165
Which IV anesthetic has both parasympathomimetic and sympatholytic properties that cause dose dependent decrease in HR and CO?
Dexmedetomidine
166
T/F flumazenil has a longer half life than the benzos it typically reverses and will be adequate even for Valium.
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
Which benzo is in acid form in its vial, then changes shape and transitions from pro-drug to active drug in the plasma pH?
Midazolam
168
Speed of recovery is inversely proportional to _
solubility (B/G)
169
The most expensive inhaled anesthetic is _
Sevo
170
Sevo is used mainly in cases with _ patients, _ patients, _ surgery, or cases < _ in duration
obese
pediatric
ambulatory
1hr
171
If hospital short on propofol, can give _ instead as they work interchangeably except for its ability to suppress seizures.
Methohexital
172
ECT cases:
-induction
-NMB
Induction: Methohexital, Propofol, Thiopental, Etomidate, Ketamine, Benzos, Sevo
NMB: Succinylcholine, Mivacurium, Atracurium, Rocuronium, Rapacurium
173
When using thiopental for ECT, it has the cardiac effect of increased _ and _s
bradycardia and PVCs
174
When using Etomidate for ECT, it causes _ seizure duration, _ recovery from post-ECT confusion and _ N/V compared to other drugs.
longer
delayed
more
175
When using Ketamine for ECT, it can cause _ ICP leading to less than desirable _ properties.
increased
analgesic
176
Drug of choice in ECT is _ because it is an ultra short barbiturate and cleared rapidly.
Methohexital
177
2nd drug of choice in ECT is _ because of its rapid emergence and elimination, but it can increase the risk of a missed seizure.
propofol
178
Haloperidol is in the butyrophenone class and if given in low doses has a high affinity for _ receptors and can produce an _ effect.
dopamine (D2)
antiemetic
179
Haldol, like Droperidol, has the negative cardiac effect of _ _.
QT prolongation
180
Which of the benzos are highly protein bound and problematic for elderly patients?
Diazepam
181
The inhaled anesthetic that offers the best bronchodilator properties is _
Sevoflurane
182
The inhaled anesthetic that lasts long and is ideal for cases with patients who will be intubated following the procedure is _
Isoflurane
183
MH is also called:
Neuroleptic Malignant Syndrome
Serotonin Syndrome
184
Symptoms of MH include:
muscle rigidity ***
EtCO2 increase (50-80)
Tachycardic
Tachypneic
High BP
Hyperkalemia
185
MH treatment drugs:
Methylene Blue or Dantrolene
Fluids (not LR)
K Cocktail
Albuterol
Kayexalate
hyperventilation
186
Don't use flows less than _ L/min of Sevo because it causes _
2L/min
hypoxemia
187
3 chemicals in body used for analgesia:
Enkephalins
Endorphins
Dynorphins
188
3 greek named opioid receptors (ORL1 receptor)
Mu
Delta
Kappa
189
When opiate receptors on the _-synaptic neuron are _, it prevents the release of Substance P, inhibiting the pain signal.
PRE-synaptic
ACTIVATED
190
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 _.
G-protein
inhibitory
depressed
191
3 factors about Opiate drugs that always are associated (due to the mu receptor):
Potency
Amount of Resp. Depression
Addiction Liability
192
Mu receptor effects:
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
Mu receptor:
-agonist
-antagonist
Agonist: endorphins, morphine, synthetic opioids
Antagonist: Naltrexone, Naloxone, and Nalmefene
194
Kappa Receptor effects:
Analgesia (supra/spinal)
DYSPHORIA/sedation
low abuse potential
miosis
ANTISHIVERING
195
Kappa receptor:
-agonist
-antagonist
Agonist: Dynorphins
Antagonist: Naloxone, Naltrexone, Nalmefene
196
Delta receptor effects:
Analgesia (supra/spinal)
Physical dependence
resp. depression
constipation - minor
urine rtn
197
Delta
-agonist
-antagonist
Agonist: Enkephalins
Antagonist: Naloxone, Naltrexone, Nalmefene
198
Most opioid effects occur on the _ receptor
Mu
199
Which 2 opioid receptors cause physical dependence?
Mu and Delta
-Kappa has least abuse potential
200
What do each opioid receptor have in common?
Common effect of analgesia at the spinal and supraspinal level
Same antagonists
201
Which opioid receptor has anti-shivering and dysphoric effects?
Kappa receptor
202
Most common way to classify opioids:
chemical structure
203
T/F If a pt is allergic to an opioid, they will be allergic to all opioids regardless of subclass.
false, pt will be allergic to all other drugs in that class most likely
204
Asthma patients should avoid opioid classes that have a histamine release effect such as _ and _. The _ subclass should be safe, however.
Phenanthrenes and Demerol
Phenylperidines
205
Other than chemical structure, opioids have subclasses that are classified by their _.
efficacy
-full agonist, partial agonist (has a ceiling effect), antagonist, etc.
206
Phenanthrene Alkaloid Naturally Occurring Agonists:
Morphine
Codeine
Thebaine
207
Phenanthrene Alkaloid Semisynthetic Agonists:
Diacetylmorphine (Heroin)
Hydrocodone (Vicodin)
Hydromorphone (Dilaudid)
Oxycodone (Oxycontin)
Tramadol
Naltrexone
Naloxone
Nalmefene
-**most common
208
Phenanthrene Alkaloid Synthetic Agonists:
-morphine derivatives
-benzmorphans
Morphine derivatives:
Levorphanol
Butorphanol
Nalbuphine
Benzmorphan:
Pentazocine
209
What is the most common subclass of opiates used?
Phenanthrene Alkaloid Semisynthetic Agonists
210
Peridine Derivative Agonists (synthetic)- Phenylpiperidines:
Meperidine (Demerol)
Loperamide
211
Peridine Derivative Agonists (synthetic)- 4-Anilidopiperidines:
Fentanyl
Sufentanyl
Alfentanyl
Remifentanyl
212
Diphenylheptane (synthetic methadone derivative) Agonists:
Methadone
213
Subclasses of Opioids (based on chem structure):
Phenanthrenes (natural, semisynth, synthetic-morphine and benzmorphan derviatives)
Piperidine Derivatives (Phenylpiperidines and 4-Anilidopiperidines)
Diphenyheptanes (methadone derivatives)
214
T/F Someone allergic to fentanyl will also be allergic to Meperidine
true
215
T/F Someone allergic to codeine can have oxycodone because they're in different classes
false, they're under the same umbrella of phenanthrene alkaloids
216
The potency of opioids is variable due to the _ _ associated with pain
emotional response
217
The opiate with the highest potency ratio is _
Sufentanyl
218
The opiate with the weakest potency ratio is _
Codeine
219
Fentanyl is in which subclass of opioids?
Piperidine Derivatives- 4-Anilidoperidine
220
Hydromorphone is in which subclass of opioids?
Phenanthrene Alkaloids-semisynthetic
221
Methadone is in which subclass of opioids?
Diphenylheptanes
222
Naltrexone is in which subclass of opioids?
Phenanthrene Alkaloids-semisynthetic
223
Why could demerol and codeine be harmful to asthmatics?
Release histamines
224
T/F If a pt has liver disease you can expect pt to need higher doses of opioids to work and last longer.
False, their disease will make meds last longer and they will require smaller doses
225
Remifentanyl is metabolized by _-_ _ enzymes via _.
non-specific esterase
hydrolysis
226
Remifentanyl lasts about _ minutes and must be given as an infusion with another med ready to give when pt wakes up.
5 mins
227
The 3 most highly protein bound opiates are:
Sufentanyl
Alfentanyl
Methadone
228
The opiate with the smallest volume of distribution is _.
Remifentanyl ( hardly leaves the plasma bc so water soluble)
~0.3-0.4L/kg
229
Which opiate has the longest elimination half life?
Methadone ~15-20hrs
230
Which opiate has the shortest elimination half life?
Remifentanyl 0.1-0.2hrs
231
Which opiate has the shortest duration?
Remifentanyl ~2-5mins
232
It's better to _-_ opiates during a case.
front-load
233
Acute effects of opiates:
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
Chronic effects of opiates:
tolerance
physical dependence
constipation
235
Which subclass of opiates can cause postural hypotension/ orthostatic hypotension?
histamine-releasing opiates: Phenanthrenes and demerol!
236
Every time an opiate is given to a pt, their _ will increase.
CO2
-eventually pt will stop breathing
237
At end of case, if pt not breathing and CO2 is at or above _ mmHg, either call APCU for a vent or give _.
50mmHg
Narcan
238
Pt's can't develop a tolerance for _ and _ in opiates
miosis and constipation
239
Which drug class can suppress cough which helps with tolerating ETT and emergence?
opiates
240
Pupils constrict with opiates due to a _ or _ effect.
parasympathomimetic or vagal
241
The vomiting center receives input from the chemotactic trigger zone via the _ _
vagus nerve
242
The _ _ _ (_) is an area in postrema of brain that senses the O2 level in blood and causes N/V.
chemotactic trigger zone
CTZ
243
Anyone who receives a _ is at higher risk for N/V and this typically occurs _ because eventually drug has an inhibiting effect on the _ _ _
narcotic
initially
CTZ chemotactic trigger zone
244
Narcotics are resp. depressors because they shift the CO2 response curve to the _, meaning it takes a _ CO2 to drive up respirations
right
higher
245
PONV risk factos:
female
<50yo
hx PONV (#1)
high dose intra/postop opiates
surg > 1hr
laproscopic procedures`
246
PDNV risk factors:
female
<50 yo
hx PONV
PONV in PACU
247
Best prophylaxis/treatment for PONV:
multimodal antiemetic therapy
248
Things that stimulate CTZ which then stimulates vomit center:
Opioids (initially)
Vestibular part of CN VIII
249
Things that inhibit CTZ and therefore inhibit vomit center:
Benzos/Propofol
Dopamine ANTAgonists
Serotonin ANTAgonists
Histamine ANTAgonists
Acetylcholine (muscarinic) ANTAgonists
Opioids (after initial dose)
250
Most widely used/gold standard antiemetic:
Ondansetron (Zofran)
251
Preferred drug for PDNV:
Palonosetron (Axoli)
252
Drug classes indicated for PONV:
Glucocorticoids
5HT3 Receptor Antagonists
Neurokinin 1 Receptor Antagonists
Antihistamines
Transdermal Scopolamine(anticholinergic)
+Metoclopramide(Reglan)
253
Dexamethasone (and methylprednisolone) for PONV should be given _ induction and _ surgery
after
before
254
Dexamethasone is thought to act as a _ antagonist on the CTZ
serotonin
255
A diabetic pt is at risk for PONV, which antiemetic drug class should be avoided in this population? Why?
glucocorticoids
-spikes BG for 6-12 hrs following admin, not nice
256
What negative effect could come with using dexamethasone or methylprednisolone for PONV?
can mask infection, delay wound healing :(
257
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?
5-HT3 Receptor Antagonists like Zofran
-prolongs QT interval leading to torsades
258
Which antiemetic can lead to serotonin syndrome with concurrent use with zofran?
Palonosetron for PDNV
259
What time is zofran typically given for a case?
beginning
-works better with dexamethasone added
260
How does Emend work as an antiemetic?
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
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?
dopamine
Parkinson's
QT prolongation
262
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?
cholinergic
Evening prior to case
263
Scopolamine patches are a great antiemetic for _ due to their effect on the vestibular nuclei but come with side effect including _, _ _, _, and _ _.
motion sickness
dizziness, dry mouth, sedation, blurred vision
-sounds like a bummer on a cruise tbh
264
Midazolam can be used prophylactically for PONV as a _ inhibitor on the CTZ but should be given _ or _.
dopamine
pre/intraoperatively
265
Metoclopramide (Reglan) is a weak _ blocker but can cause _ in high doses and has a _ half life
dopamine
dyskinesia/ EPS
short (30-40 mins)
- i get why pt were pissed with this drug, Tigan works better tbh
266
If PONV occurs within _ hrs postop, do not give the same medication class given prophylactically, use one from another class with another admin method
6
267
Common 5-HT3 Antagonists used for antiemetics:
Ondansetron (Zofran)**
Granisetron (Kytril)
Palonosetron (Aloxi) **
268
Common Dopamine Antagonists used for antiemetics:
Droperidol (Inapsine)**
Haloperidol (Haldol)**
Metoclopramide (Reglan)
Prochlorperizine (Compazine)
269
Common Antihistamines used for antiemetics:
Hydroxazine (Atarax)
Promethazine (Phenergan)
Diphenhydramine (Benadryl)
270
Common Glucocorticoids used for antiemetics:
Dexamethasone (Decadron)
Methylprednisolone (Prednisone)
271
Common Anticholinergic used for antiemetics:
Scopolamine transdermal
272
Common Neurokinin-1 Antagonists used for antiemetics:
Aprepitant (Emend)
Rolapitant (Varubi)
273
Giving a narcotic too quickly or at a high dose can cause _ _ rigidity AKA _ _, which is treated with a _ _
chest wall rigidity
tight chest
muscle relaxant
-pt can't be ventilated, too tight
274
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:
Atropine or glycopyrolate
give SL NTG
give glucagon
give naloxone
275
To treat epidural-morphine induced pruritis, give _
ondansetron
276
To prevent pruritis, you can give 3 different meds:
(follow hosp policy tho)
Droperidol
Propofol
Alizapride
277
_ can be given for antishivering properties and it works on the _ opioid receptors
Merperidine (Demerol)
KAPPA
278
Fentanyl comes in many routes of administration:
transdermal or iontophoretic transdermal
oral transmucosal (lollipops/tablets)
intranasal
transpulmonary
279
Tramadol is metabolized into the _ metabolite which is 6x as potent than its parent compound and is metabolized by the _ enzyme
M1
CYP3D6
280
Hydrocodone has varying effectiveness from genetic status of parents affecting the _ receptor binding and is metabolized by the _ enzyme
mu
CYP3D6
281
Oxycodone has significant _ and effectiveness depending on the metabolic genotype and is metabolized by the _ enzyme
VARYING
CYP3D6
282
Codeine is a _ and is metabolized into its active form, morphine and is metabolized by the _ enzyme
prodrug
CYP3D6
283
CYP3A4 enzyme metabolizes _, _, and _ in varying fashion depending on the enzymatic activity.
fentanyl
buprenorphine
methadone
284
CYP3B6 metabolizes _ and _ and women typically have higher levels of enzyme activity
propofol
methadone
285
Opioid antagonists (brand names too):
Naloxone (Narcan)
Naltrexone (Trexane, Vivitrol NT-ER)
Nalmefene (Revex)
286
Narcan titration:
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
Tell PACU RN if you gave narcan and that you are concerned with pt _
re-narcotizing
288
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
more
compete
289
What are the preferred endogenous ligands for mu receptors:
beta endorphins
met- and leu- enkephalins
290
What are the preferred endogenous ligands for the delta receptor?
met and leu enkephalins
291
What are the preferred endogenous ligands for the kappa receptor?
dynorphins
292
What is the preferred endogenous ligand for the ORL1 receptor?
nociceptin
293
Droperidol (Inapsine)
-class
-use
-extra info
dopamine blocking antiemetic
-black box warning for QT prolongation (used to be given)
294
Merperidine (Demerol)
-class
-use
-extra info
phenylpiperidine opiate
anti shivering, weaker than morphine,works on KAPPA receptor
