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ARCHIVED: Pharmacology for Nurse Anesthesia > Exam 3: Anti-Arrhythmic Agents > Flashcards

Exam 3: Anti-Arrhythmic Agents Flashcards

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1
Q

Phase 0:

A

Rapid depolarization; fast inward Na+ flow; upstroke of action potential graph

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2
Q

Phase 1:

A

Partial repolarization; Na+ channels close; ‘peak’ of AP graph

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3
Q

Phase 2:

A

Plateau; slow Ca2+ channels open; flat ‘pause’ on AP graph

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4
Q

Phase 3:

A

Repolarization; Ca2+ channels close; K+ channels open; downstroke on AP graph

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5
Q

Phase 4:

A

Pacemaker potential; slow upward stroke between APs

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6
Q

Which phases are refractory?

A

1-3

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7
Q

Normal SA rate:

A

60-100

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8
Q

Normal AV rate:

A

40-60

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9
Q

SA node resting potential:

A

-55 mV

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10
Q

Purkinje fiber firing rate:

A

15-30

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11
Q

Receptors in the atria that affect the SA node:

A

β1 and M2

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12
Q

Two types of defects in electrical activity:

A

Defect in formation of impulse

Defect in conduction of impulse

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13
Q

Define altered automaticity:

A

Latent pacemaker cells take over the SA node’s role; escape beats

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14
Q

Define delayed after-depolarization:

A

Normal AP of cardiac cell triggers train of abnormal depolarizations

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15
Q

Define re-entry:

A

Refractory tissue reactivates repeatedly/rapidly due to unidirectional block, which causes a circuit effect

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16
Q

Define conduction block:

A

Impulses that fail to propagate in non-conducting tissue (like MI-injured heart)

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17
Q

Causes of delayed after-depolarization:

A

Electrolyte abnormalities

Drug toxicities

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18
Q

Most common way arrhythmias are formed:

A

Re-entry

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19
Q

Arrythmias require tx when:

A

Cause cannot be corrected
Hemodynamic function compromised
Arrhythmia can cause more serious arrhythmias or comorbidities

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20
Q

Acute non-pharmacological tx of arrhythmias:

A

Vagal maneuvers

Cardioversion

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21
Q

Prophylactic non-pharmacological tx of arrhythmias:

A

Radiofrequency catheter ablation

Implantable defibrillator

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22
Q

Class I antiarrhythmic drugs:

A

Na+ channel blockers

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23
Q

Class II antiarrhythmic drugs:

A

β-blockers

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24
Q

Class III antiarrhythmic drugs:

A

K+ channel blockers

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25
Q

Class IV antiarrhythmic drugs:

A

Ca+ channel blockers

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26
Q

Class V antiarrhythmic drugs:

A

Unclassified

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27
Q

Class Ia agents are:

A

Intermediate Na+ channel blockers

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28
Q

Effects of class Ia agents:

A

↓ depolarization rate
↓ conduction velocity
Prolonged repolarization
↑ AP duration

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29
Q

Class Ia prototype and examples:

A

Quinidine*
Procainamide
Disopyramide
Moricizine

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30
Q

Indications for disopyramide:

A

Suppress atrial/ventricular tachyarrhythmia

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31
Q

S/E of disopyramide:

A

Myocardial depression

Can precipitate CHF/HoTN

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32
Q

Class Ib agents are:

A

Fast Na+ channel blocker

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33
Q

MoA of class Ib agents:

A

Blocks Na+ channels; doesn’t affect the rate of depolarization, but shortens AP duration and refractory

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34
Q

Prototype and examples of class Ib agents:

A

Lidocaine*
Mexiletine
Tocainide
Phenytoin

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35
Q

Indications for lidocaine:

A

Acute tx/prevention of ventricular dysrhythmias esp. immediately after MI

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36
Q

Lidocaine used after MI because:

A

Raises the vfib threshold

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37
Q

Dosing for lidocaine:

A

1 - 1.5 mg/kg IV
Infusion: 1-4 mg/min
Max dose: 3 mg/kg

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38
Q

PK of lidocaine:

A

50% protein bound
Hepatic metabolism with an active metabolite
10% renal elimination

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39
Q

Drugs/conditions that impair metabolism of lidocaine:

A

Cimetidine
Propranolol

CHF, MI, liver dysfunction, GA

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40
Q

Drugs that induce metabolism of lidocaine:

A

Barbiturates
Phenytoin
Rifampin

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41
Q

Half-time of lidocaine:

A

1.4 - 8 hrs

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42
Q

Therapeutic concentration of lidocaine:

A

1-5 mcg/ml

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43
Q

Indication for mexiletine:

A

Oral/chronic suppression of ventricular tachyarrhythmias

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44
Q

Class Ic agents are:

A

Slow Na+ channel blockers

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45
Q

MoA of class Ic agents:

A

Potent decrease of depolarization rate, decrease of conduction rate, increased AP

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46
Q

Prototype and examples of class Ic agents:

A

Flecainide*

Propafenone

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47
Q

Indications for flecainide or propafenone:

A

Ventricular PVCs, v-tach
Atrial tachyarrhythmias
WPW (flecainide)

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48
Q

S/E of flecainide:

A

Proarrhythmic

49
Q

MoA of class II agents:

A

Depress spontaneous phase 4 depolarization, decreasing SA node discharge

↓ conduction through AV node
↓ contractility

50
Q

Indications for class II agents:

A

SVT, atrial and ventricular arrhythmias

Ventricular dysrhythmias during MI/reperfusion

Tachyarrhythmias 2/2 digoxin toxicity

51
Q

Prototype and examples of class II agents:

A

Propranolol*
Metoprolol
Esmolol
Labetalol

52
Q

Indications for propranolol:

A

Prevent recurrence of tachyarrhythmias (both SVT and VT) from SNS stimulation

53
Q

Dosing of propranolol:

A

1 mg/min (total 3-6 mg) IV

10-80 mg PO

54
Q

Onset, peak, duration, half-time of propranolol:

A

Onset: 2-5 min
Peak: 10-15 min
Duration: 3-4 hrs
E1/2t: 2-4 hrs

55
Q

Cardiac effects of propranolol:

A

↓ HR, contractility, CO

↑ PVR, coronary VR

56
Q

PK of propranolol:

A 
Highly protein-bound
Hepatic metabolism (weak metabolite)
57
Q

Therapeutic plasma level of propranolol:

A

10-30 ng/ml

58
Q

S/E of propranolol:

A 
Bradycardia
Hypotension
Myocardial depression
Fatigue
Bronchospasm
Drug fever
Rash
Nausea
Raynaud's
Glucose interference
59
Q

Precautions for propranolol:

A

Reactive airway disease
Hypovolemia
CHF
AV block

60
Q

Dosing for metoprolol:

A

5mg IV over 5 min

Max dose 15 mg over 20 min

61
Q

Onset, duration, half-life of metoprolol:

A

Onset: 2.5 min

E1/2t: 3-4 hrs

62
Q

Metabolism of metoprolol:

A

Metabolized by liver

63
Q

Dosing of esmolol:

A

0.5 mg/kg IV bolus

Infusion: 50-300 mcg/kg/min

64
Q

Duration of esmolol:

A

< 15 min

65
Q

Clinical effect of esmolol:

A

↓ HR without significantly ↓ BP at small doses

66
Q

Metabolism of esmolol:

A

Plasma esterases (not the same as sux ones)

67
Q

MoA of class III agents:

A

↓ conduction velocity and prolong refractory period/action potential

68
Q

Indications for class III agents:

A

SV/V arrhythmias
Prophylaxis during cardiac surgery r/t a-fib
Preventative tx for patients w/ past cardiac death who cannot have AICD

69
Q

Prototype and examples of class III agents:

A

Amiodarone*
Dronedarone
Sotalol

70
Q

Amiodarine has properties of these classes:

A

III primarily

Also I, II, IV

71
Q

MoA of amiodarone:

A

K+/Na+/Ca+ channel blocker

ɑ- and β-blocker

72
Q

Indications for amiodarone:

A

Prophylaxis or acute tx of atrial and ventricular arrhythmias

73
Q

Amiodarone is 1st line drug when:

A

Heart is resistant to electrical defibrillation

74
Q

Dosing of amiodarone:

A

Bolus 150-300mg over 2-5 min (up to 5 mg/kg)

Infusion: 1mg/hr x 6hr, 0.5 mg/hr x 18hr

75
Q

Half-time of amiodarone:

A

29 days!!

76
Q

Metabolism of amiodarone:

A

Hepatic metabolism

Biliary/intestinal excretion

77
Q

Therapeutic level of amiodarone:

A

1.0 - 3.5 mcg/ml

78
Q

Protein binding/Vd of amiodarone:

A 
96% protein bound
Huge Vd (extensively taken into tissues)
79
Q

Administration consideration with amiodarone:

A

Can cause phlebitis - give in a large vein

80
Q

Pulmonary S/E and considerations of amiodarine:

A

Pneumonitis, fibrosis, edema, ARDS (all related to ROS) - high FiO2 can exacerbate so keep it low

81
Q

MoA of class IV agents:

A

Block slow calcium channels, primarily in the AV node

Shortens phase 2 in myocytes to ↓ contractility

82
Q

Indications for class IV agents:

A

SVT and rate control in afib/aflutter

NOT used for vent arrhythmias

83
Q

Prototype and examples of class IV agents:

A

Verapamil*

Diltiazem

84
Q

Dosing for verapamil:

A

2.5 - 10mg IV over 1-3 mins (max 20mg)

Infusion: 5 mcg/kg/min

85
Q

Contraindicated drug with verapamil:

A

β-blockers

86
Q

PK of verapamil:

A

Highly protein bound
Hepatic metabolism - active metabolite
Excreted in urine/bile

87
Q

Half-time of verapamil:

A

6-8 hrs

88
Q

S/E of verapamil:

A 
Myocardial depression
Hypotension
Bradycardia
Nausea
Prolongation of NMBs
89
Q

Dosing of diltiazem:

A

5-20 mg IV over 2 min

Infusion: 10 mg/hr

90
Q

Diltiazem vs. verapamil:

A

Diltiazem has less myocardial depression and less interaction with β blockers

91
Q

PK of diltiazem:

A

E1/2t: 4-6 hrs
Highly protein bound
Hepatic metabolism
Excreted in urine

92
Q

S/E of diltiazem:

A 
Myocardial depression
Hypotension
Constipation
Bradycardia
Nausea
Prolongation of NMBs
93
Q

Examples of class V agents:

A

Adenosine
Digoxin
Phenytoin
Atropine

94
Q

MoA of adenosine:

A

Binds to A1 purine nucleotide receptors; activates adenosine receptors to open K+ channels/increase K+ current)

End result: slows SA and AV node conduction

95
Q

Indications for adenosine:

A

Termination of SVT or diagnose VT

96
Q

Dosing for adenosine:

A

6mg IV, rapid bolus followed by flush

Repeat if needed at 3 minutes, another 6-12mg IV

97
Q

Half-time of adenosine:

A

< 10 seconds

98
Q

Metabolism of adenosine:

A

Plasma/vascular endothelial cell enzymes

99
Q

S/E of adenosine:

A 
Excessive SA/AV node inhibition
Flushing
Headache
Dyspnea
Chest discomfort
Nausea
Bronchospasm
100
Q

Contraindications for adenosine:

A

Asthma

Heart block

101
Q

MoA of digoxin:

A

Increases vagal activity, thus ↓ activity of SA node/prolongs AV conduction

↓ HR, preload, afterload

Also positive inotrope

102
Q

Dosing of digoxin:

A

0.5 - 1mg, divided doses over 12-24 hrs

103
Q

Onset, half-time of digoxin:

A

Onset: 30-60 min

E1/2t: 36 hrs

104
Q

Therapeutic level of digoxin:

A

0.5 - 1.2 ng/dl

105
Q

PK of digoxin:

A

Weak protein binding

90% excreted by kidneys

106
Q

S/E of digoxin:

A

Arrythymias, heart block, anorexia, nausea, diarrhea, confusion, agitation

107
Q

Digoxin S/E potentiated by:

A

Hypokalemia, hypomagnesemia

108
Q

Tx for digoxin toxicity:

A

Vent. arrhythmias: phenytoin
Pacing
Atropine
Antidote: digoxin immune Fab

109
Q

Indications for phenytoin:

A

Suppression of vent. arrhythmias from digoxin toxicity

Refractory torsades de pointes

110
Q

Dosage of phenytoin:

A

1.5 mg/kg IV every 5 min, up to 10-15 mg/kg

Can be painful IV!

111
Q

Therapeutic levels of phenytoin:

A

10-18 mcg/ml

112
Q

Indications for atropine:

A

Unstable bradyarrhythmias

Option for asystolic/PEA

113
Q

Dosage for atropine:

A

0.4 to 1.0 mg IV, repeat as necessary

114
Q

Onset/duration for atropine:

A

Onset: 1 min
Duration: 30-60 min

115
Q

Metabolism of atropine:

A

Hepatic

116
Q

Precaution with atropine dosing:

A

Less than 0.4mg can have paradoxical response

Penetrates BBB; has CNS effects

117
Q

Drugs for afib during arthoscopy:

A

Good heart function: amiodarone

Poor heart function: digoxin

118
Q

Drugs for SVT during a laparoscopy:

A

Normal heart function: CCB (diltiazem), β-blocker

Impaired heart function: no cardioversion; digoxin or amiodarone

119
Q

Drugs for V-tach during AAA:

A

Defib first if unstable!

Amiodarone, lidocaine, procainamide

ARCHIVED: Pharmacology for Nurse Anesthesia (20 decks)

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