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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
Propofol decreases _______, but not _____.
Propofol decreases PONV, but not PDNV.
26
Why does length of procedure increase risk of PONV?
Longer procedures = longer exposure to inhalational anesthetics and opioids
27
______ use of N2O in longer cases (>30 min)
Decrease use of N2O in longer cases (>30 min).
28
The greatest risk of PONV is ___-___ hours following surgery.
The greatest risk of PONV is 2-6 hours following surgery.
29
N2O > ____ hour increases the risk of PONV.
N2O > 1 hour increases the risk of PONV.
30
What are the risk factors for PONV in adults?
-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
What surgical procedures are associated with an increased incidence of PONV in adults?
-Laparoscopy -Cholecystectomy -Gynecological -D&C -Tooth extraction -Head & Neck surgery -GI surgery
32
Why are ENT surgeries associated with a higher incidence of PONV?
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
What surgical procedures are associated with an increased incidence of PONV in children?
-Tonsillectomy and Adenoidectomy -Orchiopexy -Middle ear surgery -Otoplasty -Strabismus repair
34
Should you use Propofol in children with Strabismus?
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
What is the Apfel Scale?
A risk score for N/V.
36
What are the risk factors for PDNV?
-Female -Hx of PONV -Age < 50 -Use of opioids in PACU -nausea in PACU -Surgery >60 minutes
37
What is a Low Risk Classification for PONV?
0-1 Risk Factors present
38
What is a Mild to Moderate Risk Classification for PONV?
20-40% risk of developing PONV 1-2 risk factors present
39
What is a Moderate to High Risk Classification for PONV?
40-80% risk of developing PONV 3-4 risk factors present
40
What is a Very High Risk Classification for PONV?
>80% risk of developing PONV >3-4 risk factors present
41
Management of N/V should originate from a _____________ rather than a _________approach, especially with patients identified as high risk.
Management of N/V should originate from a prophylactic rather than a therapeutic approach, especially with patients identified as high risk.
42
See Table 55.4 – Apfel’s Risk Assessment Tool
Yes
43
For 1-2 Risk factors, give __ anti-emetics.
2 anti-emetics.
44
For >2 Risk factors, give __ anti-emetics
3-4 anti-emetics.
45
What classes of drugs can be used for N/V Prophylaxis?
-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
What drugs should you use for rescue tx of N/V?
A drug from a different class than the prophylactic drug.
47
What are risk factors for n/v in pediatrics?
-Age >3 years -Hx of POV/PONV/motion sickness (or family hx) -Post-pubertal female -Surgery >30 min -Volatile Anesthetics -Anticholinesterases -Postop opioids
48
What are multimodal anesthetic techniques to decrease PONV?
-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
Patients who are at a higher risk for N/V, avoid ____ and give ____ instead with reversal.
Avoid neostigmine and give Sugammadex instead.
50
What are anesthetic techniques to reduce the risk of PONV?
-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
What is the 3 step approach to the management of PONV/PDNV?
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
Which antiemetics do you give at induction?
-Aprepitant -Dexamethasone -Palonosetron -Rolapitant
53
Which antiemetics do you give at the end of surgery?
-Dolasetron -Droperidol -Granisetron -Ondansetron -Ramosetron -Tropisetron
54
Which anti-emetic do you give the prior evening or 2 hr before surgery?
Scopolamine
55
What are non-pharmacologic anti-emetic mechanisms?
-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
How does P6 Stimulation help with anti-emetic?
-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
How does Neuromuscular stimulation of the median nerve have anti-emetic effects?
-Also reduces incidence of PONV early on -Better when use tetanic stimulation
58
What are other non-pharmacologic anti-emetic prophylaxis?
-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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