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Pharm Exam 5 -- Smooth Muscle, GI and OTC > GI (pt 5/5) PONV cont. > Flashcards

GI (pt 5/5) PONV cont. Flashcards

1
Q

What is the MOA for Phenothiazines for N/V prevention?

A

Block dopamine and muscarinic receptors and depending on their structure anti-histamine effects.

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2
Q

What are the side effects associated with Phenothiazines?

A

-Sedation, dry mouth – due to their antihistamine activity (not rly used in anesthesia because of sedation)
-Dystonic reactions- dopamine antagonism, decrease BP
-Deep IM inj., good working IV- tissue necrosis, gangrene risk (may want to dilute, make sure IV is working well)

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3
Q

What are the example drugs of Phenothiazines used for N/V Prevention?

A

Prochlorperazine (Compazine)
Promethazine (Phenergan)
Thiethylperazine (Torecan)

Antipsychotic agents used for their antiemetic properties.

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4
Q

What is the MOA of Butyrophenones (Droperidol)?

A

-Antipsychotic with antiemetic properties
-Block central dopaminergic receptors

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5
Q

What are the side effects associated with Butyrophenones (Droperidol)?

A

-Sedation, dystonic reactions
-CNS effects – hallucinations, post-anesthesia delirium, depression, nightmares, decreased seizure threshold
-Hypotension – especially with epidural or spinal anesthesia
-Black Box Warning – may prolong QT interval 🡪 ventricular tachycardia including torsades de pointes

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6
Q

What patients should you NOT use Droperidol (Butyrophenones) with? (Blue Box!!)

A

DO NOT use with QT prolongation & only used in patients who have not responded to alternative antiemetic agents.

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7
Q

What is the MOA for Substituted Benzamides (Metoclopramide and Trimethobenzamide) for N/V?

A

Block Dopamine Receptors in CTZ

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8
Q

What are the adverse effects associated with Substituted Benzamides (Metoclopramide and Trimethobenzamide) for N/V?

A

Extrapyramidal – restlessness, dystonias, & parkinsonian symptoms

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9
Q

What are the two First generation histamine H1 Antagonists with significant anticholinergic properties used for N/V?

A

Diphenhydramine (Benadryl ) & Dimenhydrinate (Dramamine)

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10
Q

What is an H1 Antihistaminic agent with minimal anticholinergic properties used for N/V?

A

Meclizine

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11
Q

What is Hyoscine Hydrobromide (Scopolamine)?

A

A Prototypical muscarinic receptor antagonist.
-Transdermal patch needs to be placed night before surgery or 2 hours before surgery for best effect.
-Best agent for the prevention of motion sickness.

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12
Q

What is the MOA for H1 Antihistamines and Anticholinergic Drugs in prevention of N/V?

A

Interrupt visceral afferent pathways in the GI tract.
-Weak antiemetic activity – better for simple N&V
-Useful for the prevention or treatment of motion sickness (Scopolamine)

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13
Q

What are the side effects associated with H1 Antihistamines and Anticholinergic Drugs? (Limit their use for N/V)

A

Dizziness
Sedation
Confusion
Dry mouth
Urinary retention

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14
Q

What Benzodiazepines can be used before the initiation of chemotherapy to reduce anticipatory vomiting or vomiting caused by anxiety?

A

Lorazepam (Ativan) or Diazepam (Valium)

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15
Q

Which benzodiazepine, when given 30 min before the end of surgery, is shown to be as effective as Zofran?

A

Midazolam (however, risk of sedation)

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16
Q

What are the example drugs of the Cannabinoids that are used for N/V prevention?

A

Dronabinol (Marinol) & Nabilone (Cesamet)

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17
Q

What are the medical uses of the Cannabinoids?

A

-Stimulate appetite
-Prevent chemotherapy-induced nausea and vomiting

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18
Q

What is the combo therapy used with Cannabinoids?

A

Combotherapy with phenothiazines: Synergistic antiemetic action and appears to attenuate the adverse effects of both agents

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19
Q

What are the adverse effects of the Cannabinoids?

A

High incidence of SEs associated with use.
-Euphoria
-Dysphoria
-Sedation
-Hallucinations
-Dry mouth
-Autonomic effects: Tachycardia & orthostatic hypotension
-May potentiate the clinical effects of other psychoactive agents

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20
Q

What is Propofol?

A

A sedative/hypnotic that has anti-emetic properties in subclinical doses.
-Used in TIVA
-Decreases risk of PONV in first 6 hrs
-Not effective for PDNV

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21
Q

PONV effects ___ - ___% of patients, and ___-___% of high risk patients.

A

Effects 20% - 30% of patients, and 70%-80% of high risk patients.

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22
Q

The Incidence of vomiting is __ nausea.

A

The Incidence of vomiting is < nausea.

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23
Q

What are the Inhalation Agents with risk of producing PONV, listed from greatest to least?

A

-Halothane
-Enflurane
-Isoflurane
-Desflurane
-Sevoflurane

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24
Q

What is the strongest predictor of PONV?

A

The use of volatile anesthetics.
-Sevo causes the least amount of PONV.

25
Q

Propofol decreases _______, but not _____.

A

Propofol decreases PONV, but not PDNV.

26
Q

Why does length of procedure increase risk of PONV?

A

Longer procedures = longer exposure to inhalational anesthetics and opioids

27
Q

______ use of N2O in longer cases (>30 min)

A

Decrease use of N2O in longer cases (>30 min).

28
Q

The greatest risk of PONV is ___-___ hours following surgery.

A

The greatest risk of PONV is 2-6 hours following surgery.

29
Q

N2O > ____ hour increases the risk of PONV.

A

N2O > 1 hour increases the risk of PONV.

30
Q

What are the risk factors for PONV in adults?

A

-Female sex
-History of PONV or motion sickness
-Nonsmoking
-Younger age
-General vs Regional Anesthesia
-Use of Volatile anesthetics & N2O
-Use of postop opioids
-Duration of anesthesia >1 hr
-Type of surgery (Cholecystectomy, Laparoscopic, gynecological)

31
Q

What surgical procedures are associated with an increased incidence of PONV in adults?

A

-Laparoscopy
-Cholecystectomy
-Gynecological
-D&C
-Tooth extraction
-Head & Neck surgery
-GI surgery

32
Q

Why are ENT surgeries associated with a higher incidence of PONV?

A

Especially occurs with Middle Ear Surgeries.
-Accumulation of blood in the posterior oropharynx, which may drain into the stomach or be swallowed during the post-op period can cause PONV
-Pack the back of the throat
-OGT at the end of the procedure to remove gastric contents/blood

33
Q

What surgical procedures are associated with an increased incidence of PONV in children?

A

-Tonsillectomy and Adenoidectomy
-Orchiopexy
-Middle ear surgery
-Otoplasty
-Strabismus repair

34
Q

Should you use Propofol in children with Strabismus?

A

In children with Strabismus, propofol can increase the oculocardiac reflex in these kids (severe bradycardia). Give a little glyco if using TIVA during these surgeries.

35
Q

What is the Apfel Scale?

A

A risk score for N/V.

36
Q

What are the risk factors for PDNV?

A

-Female
-Hx of PONV
-Age < 50
-Use of opioids in PACU
-nausea in PACU
-Surgery >60 minutes

37
Q

What is a Low Risk Classification for PONV?

A

0-1 Risk Factors present

38
Q

What is a Mild to Moderate Risk Classification for PONV?

A

20-40% risk of developing PONV
1-2 risk factors present

39
Q

What is a Moderate to High Risk Classification for PONV?

A

40-80% risk of developing PONV
3-4 risk factors present

40
Q

What is a Very High Risk Classification for PONV?

A

> 80% risk of developing PONV
3-4 risk factors present

41
Q

Management of N/V should originate from a _____________ rather than a _________approach, especially with patients identified as high risk.

A

Management of N/V should originate from a prophylactic rather than a therapeutic approach, especially with patients identified as high risk.

42
Q

See Table 55.4 – Apfel’s Risk Assessment Tool

A

Yes

43
Q

For 1-2 Risk factors, give __ anti-emetics.

A

2 anti-emetics.

44
Q

For >2 Risk factors, give __ anti-emetics

A

3-4 anti-emetics.

45
Q

What classes of drugs can be used for N/V Prophylaxis?

A

-5HT3 Receptor antagonists
-Corticosteroids
-Antihistamines
-Dopamine Antagonists
-Propofol
-NK-1 Receptor Antagonists
-Anticholinergics
-Acupuncture

Basically, give everyone Decadron and Zofran prophylactically (unless c/i like in brittle diabetics).

46
Q

What drugs should you use for rescue tx of N/V?

A

A drug from a different class than the prophylactic drug.

47
Q

What are risk factors for n/v in pediatrics?

A

-Age >3 years
-Hx of POV/PONV/motion sickness (or family hx)
-Post-pubertal female
-Surgery >30 min
-Volatile Anesthetics
-Anticholinesterases
-Postop opioids

48
Q

What are multimodal anesthetic techniques to decrease PONV?

A

-Prophylactic IV acetaminophen (before the onset of pain)
-Perioperative NSAIDs and Cox 2 inhibitors (caution- may cause anastomosis leakage)
-Ketamine intra op but less so then Acetaminophen and NSAIDS
-Alpha 2 agonists like Dexmedetomidine and clonidine to decrease post op pain, opioid consumption and PONV. Prophalactic .5/ug/kg deduced pain at 1 hour post op and POD 1-3 pt were faster to get back to ADL’s.
-Epidural, TAP blocks, continuous wound infiltration with local
-TIVA and volatile were the same when you add a 5HT3 blocker and droperidol
-Propofol at subhypnotic doses with anti-emetic also decreased PONV
-PONV lower with suggammadex then with Neostigmine
-Lidocaine infusion with abd laporoscopic procedures was lower with lido infusion

49
Q

Patients who are at a higher risk for N/V, avoid ____ and give ____ instead with reversal.

A

Avoid neostigmine and give Sugammadex instead.

50
Q

What are anesthetic techniques to reduce the risk of PONV?

A

-Avoid GA (use RA)
-Use propofol
-Avoid N2O in surgery > 1 hr
-Avoid Volatile anesthetics
-Minimize opioids
-Adequate hydration
-Avoid Neostigmine and give Sugammadex

51
Q

What is the 3 step approach to the management of PONV/PDNV?

A

1) Risk assessment for prevention
2) Adjustment of preventive measures used
-May include a modification of the anesthesia technique
3) Follow-up with use of rescue treatment immediately by targeting mechanisms that have not yet been tried
-May include non-pharmacologic methods

52
Q

Which antiemetics do you give at induction?

A

-Aprepitant
-Dexamethasone
-Palonosetron
-Rolapitant

53
Q

Which antiemetics do you give at the end of surgery?

A

-Dolasetron
-Droperidol
-Granisetron
-Ondansetron
-Ramosetron
-Tropisetron

54
Q

Which anti-emetic do you give the prior evening or 2 hr before surgery?

A

Scopolamine

55
Q

What are non-pharmacologic anti-emetic mechanisms?

A

-Acupuncture
-Transcutaneous electrical nerve stimulation (TENS): Place it over the acupuncture point of the wrist
-Acupoint stimulation
-Acupressure
-P6 stimulation
-Korean hand acupoints
-Controlled breathing
-Isopropyl alcohol

56
Q

How does P6 Stimulation help with anti-emetic?

A

-Decreases N&V and need for rescue antiemetics
-Similar to using Zofran, droperidol and reglan
-Adults and Children alike
-Timing doesn’t matter before/after induction
-10 different acupuncture modalities

57
Q

How does Neuromuscular stimulation of the median nerve have anti-emetic effects?

A

-Also reduces incidence of PONV early on
-Better when use tetanic stimulation

58
Q

What are other non-pharmacologic anti-emetic prophylaxis?

A

-IV fluid therapy-no difference in colloid vs crystalloid
-Low dose Narcan infusion
-Noni-fruit -600mg
-Ginger 1gm 1 hour before induction

Pharm Exam 5 -- Smooth Muscle, GI and OTC (10 decks)

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