Induction Drugs

Question 1

Gold standard for IV anesthetics

Answer 1

Barbs

Question 2

barbituric acid is composed of

Answer 2

urea + malonic acid

Question 3

Barbs: sedative & hypnotic properties are determined by alterations in which carbon atoms?

Answer 3

2 & #5

Question 4

Name the oxybarbiturates

Answer 4

Methohexital
Phenobarbital
Pentobarbital
Secobarbital

Question 5

The characteristic effect of methohexital due to methyl group on the nitrogen

Answer 5

Increased risk of excitatory phenomenon, seizures, and hiccoughs

Question 6

The phenyl group at the #5 position for Phenobarbital leads to what drug effect?

Answer 6

increased anticonvulsant properties

Question 7

How do pentobarbital and secobarbital differ in chemical structure from the other oxybarbiturates?

Answer 7

O2 atom at the #2 carbon atom

Question 8

Name the two Thiobarbiturates.

Answer 8

Thiopental
Thiamylal

Question 9

How does the chemical structure of thiobarbiturates differ, and what does this mean for the drug characteristics?

Answer 9

There is sulfur at the #2 carbon atom. This leads to increased lipid solubility and hypnotic potency.

Question 10

Barbs MOA

Answer 10

Increase affinity for GABA. Barbs can also mimic GABA and activate chloride channels even with no GABA present.

Question 11

How does the metabolism of oxybarbs and thiobarbs differ?

Answer 11

Oxybarbs = Liver
Thiobarbs = Liver, Kidney, Brain

Question 12

Intra-arterial injection of which barb can lead to cyanosis and gangrene?

Answer 12

Thiobarb

Question 13

What effect does sustained delivery of barbs have on liver enzymes, and which medication is the biggest culprit?

Answer 13

Liver enzymes are induced leading to increased metabolism of drugs. Phenobartibal is the most potent liver enzyme inducer.

Question 14

Liver enzyme induction accelerates the metabolism of which drugs?

Answer 14

oral anticoagulants
phenytoin
TCA
corticosteroids
bile salts
vitamin K

Question 15

What is Porphyria, and what drug class is avoided by patients presenting with it?

Answer 15

The autosomal dominant disease leads to defective heme metabolism. This leads to neurological damage, peripheral and autonomic neuropathies, and psychiatric manifestations.
Barbiturates should be avoided.

Question 16

Why are barbiturates bad for patients with AIP?

Answer 16

Barbiturates accelerate heme production. AIP presents as a defect in heme metabolism which leads to excessive accumulation of heme, eventually leading to acute attacks and death.

Question 17

Categorize the BZ by their elimination half-life.

Answer 17

Short: Midazolam
Intermediate: Lorazepam
Long: diazepam

Question 18

T 1/2 of Midazolam?

Answer 18

<6 hours

Question 19

T 1/2 of Lorazepam?

Answer 19

6-24 hours

Question 20

T 1/2 of Diazepam?

Answer 20

24-37 hours

Question 21

BZ MOA

Answer 21

BZ bind to GABBA-A receptors and modulates their activity (enhances affinity). GABA is required as BZ are unable to open chloride channels without them.

Question 22

The imidazole ring found in BZ requires what state to increase lipid solubility, and under what circumstances does this occur?

Answer 22

Closed state, and occurs at physiological pH.

Question 23

Which BZ are preferred for increased age and liver disease, and why?

Answer 23

Lorazepam, oxazepam, temazepam.
These are metabolized by glucuronidation, which is not effected by age or liver disease.

Question 24

A symptom of BZ withdrawal in the elderly presents as what?

Answer 24

Confusion

Question 25

Long-term use of BZ leads to two significant things in the patient population.

Answer 25

Tolerance & cognitive decline

Question 26

BZ produce more _____ than sedation.

Answer 26

amnesia

Question 27

PO administration of which drug has a high first-pass hepatic extraction.

Answer 27

Midazolam

Question 28

Drugs that inhibit CYP450 enzymes and prolong metabolism include (5).

Answer 28

Fentanyl Erythromycin CCB Antifungals Cimetidine

Question 29

CNS effects include anterograde amnesia.

Answer 29

Midazolam

Question 30

Respiratory effects of Midazolam

Answer 30

decreased TV increased RR

Question 31

May increase cardiac output in CHF patients.

Answer 31

Midazolam

Question 32

Modest CV effects include decreased ABP and increased HR.

Answer 32

Midazolam

Question 33

Most common preoperative sedative in adults and children.

Answer 33

Midazolam

Question 34

Used prophylactically to raise seizure threshold when performing regional blocks

Answer 34

BZ

Question 35

Avoid this bz medication in pregnant patients

Answer 35

Midazolam

Question 36

Po administration results in 100% bioavailability.

Answer 36

Diazepam

Question 37

Mixing with NS or water for dilution results in cloudiness.

Answer 37

Diazepam

Question 38

This medication crosses the placenta, resulting in fetal concentrations equal to or greater than the mother

Answer 38

Diazepam

Question 39

Which active metabolite of a BZ contributes to sustained drug effects and return of drowsiness 6-8 hours after administration?

Answer 39

Desmethyldiazepam

Question 40

Which drug can decrease LVED pressure with small doses?

Answer 40

Diazepam

Question 41

Minimal CV effects with this drug. They equate to natural sleep.

Answer 41

Diazepam

Question 42

Used to produce skeletal muscle relaxation in lumbar disc disease.

Answer 42

Diazepam

Question 43

This BZ is the most potent sedative and amnesic.

Answer 43

Lorazepam

Question 44

BZ with a slower onset due to lower lipid solubility.

Answer 44

Lorazepam

Question 45

This is the only BZ that has no active metabolites.

Answer 45

Lorazepam

Question 46

Contraindicated in patients on antiepileptic drugs.

Answer 46

Flumazenil

Question 47

Propofol induction dose

Answer 47

1.5-2.5mg/kg

Question 48

Propofol onset of action

Answer 48

30 seconds

Question 49

This drug promotes bacterial growth

Answer 49

Propofol

Question 50

This drug contains metabisulfate, known to exacerbate asthma and trigger sulfate allergies.

Answer 50

Generic propofol

Question 51

This drug is a low lipid emulsion that is preservative-free, however, there remains significant pain with injection

Answer 51

Ampofol

Question 52

This drug produces formaldehyde byproducts leading to perineum burning.

Answer 52

Fospropofol

Question 53

A propofol syringe needs discarding after how many hours?

Answer 53

6

Question 54

The mixing of what two drugs lead to fat emboli

Answer 54

Propofol + Lidocaine

Question 55

Propofol pKa

Answer 55

11

Question 56

Propofol EHL

Answer 56

0.5-1.5 hours

Question 57

Propofol Vd

Answer 57

1000-4000 L

Question 58

How is the induction dose of propofol adjusted for elderly patients, and why?

Answer 58

Decrease the dose by 25-50%. Elderly patients have experience increased drug effects and decreased clearance of the drug.

Question 59

Off-Label uses for Propofol

Answer 59

Antiemetic Antipruritic Anticonvulsant diminish bronchoconstriction

Question 60

Which drug contains a preservative resulting in allergies and bronchoconstriction.

Answer 60

Propofol (Diprivan)

Question 61

Propofol: MAC v. GA dosages

Answer 61

MAC: 25-100mcg/kg/min GA: 100-300mcg/kg/min

Question 62

Hypnosis with Propfol lasts how long?

Answer 62

5-10 minutes

Question 63

Propofol respiratory effects

Answer 63

decreased TV, RR, and response to hypoxia

Question 64

How does a propofol dose of 2-2.5mcg/kg impact CV.

Answer 64

40% drop in BP, CO, SVR, and reduced myocardial consumption.

Question 65

Propofol CV effects

Answer 65

decreased BP, HR unchanged, blunted baroreceptor reflex

Question 66

What is propofol infusion syndrome?

Answer 66

high doses of propofol + steroids = multi-organ failure, AKI (rhabdo)

Question 67

Etomidate pKa

Answer 67

4.24

Question 68

Etomidate induction dose

Answer 68

0.2-0.4mg/kg

Question 69

Etomidate has two isomeric forms. Which isomer has hypnotic/sedative properties?

Answer 69

S (+)

Question 70

Etomidate metabolism

Answer 70

Liver enzymes & plasma esterases

Question 71

Flumazenil has no effect on this non-barb drug.

Answer 71

Etomidate

Question 72

Etomidate EHL

Answer 72

2-5 hours

Question 73

Etomidate: special CNS considerations

Answer 73

It causes myoclonus and may activate seizures.

Question 74

Drug known for its hemodynamic stability

Answer 74

Etomidate

Question 75

Etomidate respiratory effects

Answer 75

decreased TV, increased RR, decreased response to CO2, hiccoughs, emergence excitement

Question 76

High incidence of PONV

Answer 76

Etomidate

Question 77

Good drug to use for patients with reactive airway disease.

Answer 77

Etomidate

Question 78

First choice drug category for alcohol detox.

Answer 78

BZ

Question 79

Ketamine induction dose

Answer 79

1-2mg/kg

Question 80

Only agent producing dissociate anesthesia

Answer 80

Ketamine

Question 81

Drug contains potent analgesic properties

Answer 81

Ketamine

Question 82

Ketamine pKa

Answer 82

7.5

Question 83

This drug is not extensively protein-bound, unlike other induction agents.

Answer 83

Ketamine

Question 84

Commercial preparations given as a racemic mixture

Answer 84

Ketamine

Question 85

Ketamine EHL

Answer 85

2-3 hours

Question 86

What are the effects of norketamine?

Answer 86

1/3-1/5 potency, which leads to prolonged drug effects

Question 87

Ketamine MOA

Answer 87

NMDA antagonist minor GABA action

Question 88

Suppresses inflammatory mediators which improve blood flow

Answer 88

Ketamine

Question 89

Ketamine CNS effects

Answer 89

increase CBF, CMRO2, ICP antidepressant, potentiates NDNMB, emergence delirium, nystagmus

Question 90

Emergence delirium with Ketamine is more prevelent in what patient population?

Answer 90

Women 15 years of age and older with a history of personality disorder or dreaming, and with doses of 2mg/kg or more.

Question 91

What can attenuate emergence delirium seen with Ketamine?

Answer 91

Midazolam

Question 92

Ketamine respiratory effects

Answer 92

Bronchodilation increased secretions

Question 93

Ketamine CV effects

Answer 93

increased BP, HR, CO release of NE, and inhibits uptake increased PVR and RV workload

Question 94

It acts as a direct myocardial depressant and is not recommended for patients with CAD.

Answer 94

Ketamine

Question 95

Ketamine LOC

Answer 95

30-60 seconds

Question 96

Ketamine return of consciousness time v. return of awareness

Answer 96

consciousness 10-20minutes awareness 60-90 minutes

Question 97

Ketamine chemical compound is a derivative of?

Answer 97

PCP

Question 98

Chronic Ketamine use causes what metabolic phenomenon to occur?

Answer 98

Enzyme induction which quickens the metabolism of ketamine leading to drug tolerance

Question 99

Dexmedetomidine MOA

Answer 99

Alpha 2 adrenergic agonist

Question 100

Decreased SNS activity seen with dexmedetomidine is caused by?

Answer 100

Decrease in NE levels

Question 101

Dexmedetomidine EHL

Answer 101

2-3 hours

Question 102

Dexmedetomidine dosing

Answer 102

Loading: 1mcg/kg (10min) maintenance: 0.2-1mcg/kg/hr

Question 103

Dexmedetomidine adverse effects

Answer 103

hypotension hypertension (loading phase) Nausea Bradycardia Anemia Hypothermia

Question 104

Exercise extreme cause in using this drug with patients diagnosed with severe heart block and/or severe ventricular dysfunction.

Answer 104

Dexmedetomidine

Question 105

Dexmedetomidine: CSHF of a 4 min infusion v. a 250 min infusion

Answer 105

4 min = 10 min 250 min = 8 hours