Exam 5 (drugs only)

Question 1

4 IV anesthetics used for induction

• name
• which one has rapid induction/emergence?
• good to use with hypotensive patients?
• hallucinations?
• inhibits cortisol?
• alpha-2 adrenergic agonist?
• analgesic effects
• does NOT cause respiratory depression

Answer 1

1. Propofol
   - rapid induction/emergence
2. Ketamine
   - sympathomimetic and vagolytic
   - good for hypotensive patients
   - hallucinations
3. Etomidate
   - inhibits cortisol
   - increased risk of death
4. Dexmedetomidine
   - alpha-2 adrenergic agonist
   - analgesia
   - no respiratory depression so good for people with critical breathing

Question 2

When is etomidate and good choice for IV anesthesia induction?

Answer 2

Severe cardiomyopathy - does not alter hemodynamics

Question 3

Divide the 4 inhalation anesthetics in volatile vs gaseous

Answer 3

Volatile

• isoflurane
• desflurane
• sevoflurane

Gaseous
-nitrous oxide

Question 4

Desflurane vs sevoflurane

• which one has lower solubility?
• Faster increase in [alveolar]?

Answer 4

-desflurane has lower solubility and faster uptake

Question 5

Side effects of nitrous oxide?

Answer 5

• Bone marrow depression
• Peripheral neuropathies w/ long term exposure
• Diffusion into and expansion of closed gaseous spaces

Question 6

Side effect of halothane?

Answer 6

• Hepatic metabolites could cause immune reaction
-Immune-mediated hepatitis
• No longer used

Question 7

Isoflurane vs. desflurane vs. sevoflurane

• which one is the least pungent volatile anesthetic?
• bronchodilator?
• weak coronary vasodilator?
• low solubility -> rapid induction/emergence
• tachycardia and HTN risk

Answer 7

• Isoflurane
– Weak coronary vasodilator

• Desflurane
– Low solubility – rapid induction and emergence
– Rapid increases in concentration can produce tachycardia and hypertension

• Sevoflurane
– Least pungent volatile anesthetic
– Bronchodilator

Question 8

Name 3 drugs better than warfarin for txing anticoagulation in afib patients

Answer 8

Dabigatran
Apixaban
Rivaroxaban

-less intracranial bleeding and more effective

Question 9

Carbamazepine (Tegretol)

• indications
• pharmacokinetics
• adverse effects

Answer 9

 Indication: partial onset seizures only

 Pharmacokinetics: liver metabolized, moderate protein binding, many interactions

 Adverse effects: drowsiness, nausea, dizziness, visual disturbance. Rash 5%. Rare: aplastic anemia, severe rash, liver failure ~1/200,000

Question 10

Phenytoin (Dilantin)

Answer 10

  Indications: partial and generalized onset

 Pharmacokinetics: non-linear with
clinically important saturation, highly
protein bound, many interactions

 Adverse effects: drowsiness, dizziness, unsteady gait, gum hypertrophy. Rash ~5%. Rare liver failure, aplastic anemia, severe rash

Question 11

Lamotrigine (Lamictal)

Answer 11

 Indications: partial or generalized onset seizures

 Pharmacokinetics: liver metabolized, low protein binding, few interactions

 Adverse effects: sedation is uncommon, dizziness. Rash ~5%. Rare severe rash

Question 12

Levetiracetam (Keppra)

Answer 12

 Indications: partial or generalized onset seizures

 Pharmacokinetics: not liver metabolized, no protein binding, no important interactions

 Adverse effects: drowsiness, irritability. Rash, liver failure, aplastic anemia not seen

Question 13

Valproate (Depakote)

Answer 13

 Indications: partial or generalized onset seizures (drug of choice for most generalized onset seizures; be wary of teratogenesis)

 Pharmacokinetics: liver metabolized, highly protein bound, many interactions

 Adverse effects: drowsiness, weight gain, tremor, hair loss. Rash rare. Liver failure rare but more common in children.

Question 14

What is the least sedating anticonvulsant?

Answer 14

Lamotrigine

Question 15

Anticonvulsant with least drug ix and protein binding?

Answer 15

levetiracetam

Question 16

Drugs of choice for partial seizure

Answer 16

carbamazepine, levetiracetam, lamotrigine

Question 17

Generalized onset seizure drug of choice

Answer 17

Valproate

Question 18

Drugs that induce metabolism of other drugs

Answer 18

Carbamazepine and phenytoin

Question 19

Drugs that inhibit metabolism of other drug

Answer 19

Valproate

Question 20

Drugs that are highly protein bound

Answer 20

Valproate and phenytoin

Question 21

1. Therapeutic range for phenytoin
2. Guidelines for dose increase
   If level < 7
   If level 7 - 11
   If level > 11

Answer 21

1. 10 - 20 mcg/ml
2. Guidelines
    if level < 7, increase daily dose 100 mg
    if level 7-11, increase daily dose 50-60 mg
    if level > 11, increase daily dose 25-30 mg

Question 22

Midazolam.

• anesthesia stage
• class
• half life
• elimination

Answer 22

• premedication
• benzodiazepine
• 6 hours (short)

Elimination
-redistribution is most important
•  Conjugated to glucuronides
•  Eliminated by the kidney
•  Elimination slowed in the elderly, critically ill (especially in sepsis)

Question 23

2 opioids used for anesthesia premedication.

• elimination
• which has longer half life

Answer 23

Morphine

• has active metabolite M6G
• eliminated through urine
• acidemia prolongs half life

Fentanyl
• Short duration of action after a single dose due to high lipid solubility & redistribution

• Elimination half-life is longer than that of morphine (2-16 h v. 1.5-6 h)