ITE CA2 pharm 4 Flashcards
Hexamethonium
Hexamethonium is an example of a ganglionic blocking drug which acts as an antagonist at the neuronal-type nicotinic receptors
neuronal-type nicotinic receptor blockers
hexamethonium, trimethaphan, and mecamylamine
can you dialyze off
apixaban
dabigatran
rivaroxaban
apixaban - no
dabigatran - partially
ravaroxaban - no
Bivalirudin
Bivalirudin is a direct thrombin inhibitor with a relatively short half-life (25 minutes in patients with normal renal function; up to three hours in dialysis-dependent individuals). Its primary application is in patients undergoing percutaneous coronary intervention (PCI). As of 2018, there is no known antidote. Given its short half-life, treatment of hemorrhage is primarily supportive
Dabigatran
mechanism
reversal
Idarucizumab is a monoclonal antibody fragment that binds to the active site of dabigatran, a direct thrombin inhibitor with oral bioavailability. It is used for the management of serious bleeding caused by dabigatran but does not appear to be effective against bleeding caused by other direct thrombin inhibitors (such as bivalirudin or argatroban).
Andexanet alfa
Andexanet alfa is a recombinant derivative of factor Xa, and acts as a “decoy receptor”, effectively binding factor Xa inhibitors (such as rivaroxaban, apixaban, and edoxaban) with higher affinity than factor Xa itself. Its approval represents an important step forward in anticoagulation management, as direct factor Xa inhibitors (like rivaroxaban and apixaban) continue to grow in popularity. Direct factor Xa inhibitors have oral bioavailability, do not require laboratory monitoring or have special dietary requirements (unlike warfarin), and have relatively attractive side effect profiles.
Andexanet alfa is approved for the management of major bleeding resulting from treatment with direct factor Xa inhibitors such as rivaroxaban, apixaban, and edoxaban.
Unlike most anesthetics which directly depress the RAS, ketamine exerts its effects on the ______, causing dissociation of the _____________________.
Unlike most anesthetics which directly depress the RAS, ketamine exerts its effects on the thalamus, causing dissociation of the reticular activating system from the cerebral and limbic cortices.
Amiodarone
MoA
Use
Amiodarone is a class III antiarrhythmic agent with a primary effect of blocking potassium channels. It also blocks calcium and sodium channels to a lesser effect as well as α- and β-adrenergic receptors. The approved clinical use of amiodarone is limited to refractory ventricular arrhythmias. Recall that amiodarone is still the antiarrhythmic agent of choice in the setting of CHF or low ejection fraction.
Amiodarone is contraindicated in
Amiodarone is contraindicated in the setting of heart block and preexisting bradycardia.
side effects of amiodarone include
Important side effects of amiodarone include bradycardia, hypotension, hypothyroidism, life-threatening hyperthyroid storm, pulmonary toxicity (with a pulmonary fibrosis appearance), prolonged QT interval, and elevated liver function markers.
Amiodarone is known to create extensive tissue deposits which lead to skin hypersensitivity and hyperpigmentation, described as a blue-grey appearance.
Amiodarone half life
Even when amiodarone is discontinued, there is still a risk of toxicity because of the drug’s long 45 day half-life.
The risk of amiodarone-induced pulmonary toxicity correlates more with the total cumulative dose than with the daily dose or plasma concentration.
chronic dantrolene use, what lab monitor
Chronic dantrolene use has been associated with liver dysfunction and potentially fatal liver failure, thus liver function testing (LFT) should be routinely monitored.
when use steroids for pain
Corticosteroids such as methylprednisolone are not used for management of chronic diabetic neuropathic pain, but may be beneficial during the acute phase of herpes zoster
treatment of chronic diabetic neuropathy
methadone, tramadol, antiepileptics (such as gabapentin or carbamazepine), antidepressants (such as tricyclic antidepressants (TCAs), including desipramine and amitriptyline), and SNRIs.
Drugs which can cause hyperkalemia include
Drugs which can cause hyperkalemia include beta blockers, nonsteroidal anti-inflammatory drugs, spironolactone, heparin, and angiotensin-converting enzyme inhibitors
Patients who are hyperkalemic can present with
Patients who are hyperkalemic can present with weakness, palpitations, bradycardia, nausea, vomiting, and paralysis.
MoA for TXA and aminocaproic acid
tranexamic acid (TXA) or aminocaproic acid, both of which work by binding plasminogen and plasmin, effectively preventing further breakdown of fibrin.
MoA tPA
enzymatic catalyst for conversion of plasminogen to plasmin
MoA protamine
direct binding of large negatively charged heparin molecules in the serum
MoA DDAVP
induction of synthesis of von willebrand factor by endothelial cells
type of steroid dexamethasone
glucocorticoid
patient on chronic steroids do they need mineralcorticoid peri-op
no (secondary adrenal insufficiency)
most current literature suggests that dexamethasone alone is appropriate for prophylaxis in patients with possible secondary adrenal insufficiency (e.g. due to steroid use). Mineralocorticoid prophylaxis is most appropriate for patients with primary adrenal insufficiency (unrelated to chronic steroid use).
which drugs can cause anticholinergic syndrome
what drug to treat it
Atropine and scopolamine can produce a central anticholinergic syndrome, which can only be treated with physostigmine, 1-2 mg IV (neostigmine and pyridostigmine do not pass into the CNS)
Phenelzine
Phenelzine is a monoamine oxidase inhibitor (MAOI) used for treatment-resistant depression. MAOI therapy results in increased serotonin in synaptic clefts. Can cause serotonin syndrome
signs of serotonin syndrome
key difference b/t serotonin syndrome and central anticholinergic syndrome
Signs of serotonin syndrome include clonus, hyperreflexia, tachycardia, hyperpyrexia, diaphoresis, ataxia, and confusion. The most accurate diagnostic criteria currently are the Hunter Toxicity Criteria Decision Rules. Criteria are met when the patient has one of the following:
- Spontaneous clonus
- Inducible clonus plus agitation or diaphoresis
- Ocular clonus plus agitation or diaphoresis
- Tremor plus hyperreflexia
- Hypertonia plus temperature > 38 °C plus ocular clonus or inducible clonus
Note that diaphoresis is more common with serotonin syndrome. In contrast, xeroderma (dry skin) is more common with central anticholinergic syndrome (CAS).
name 3 TCAs
amitriptyline, nortriptyline, dosulepin
name 3 irreversible MAO-Is
phenelzine, tranylcypromine, and isocarboxazid
name 1 reversible MAO-I
moclobemide
2 drugs to avoid if someone on MAOI
meperidine and indirect-acting vasopressors (ephedrine)
how long discontinue prior to spinal clopidogrel ticlopidine fondaparinux garlic ginko ginseng warfarin
clopidogrel - 7 days ticlopidine - 14 days fondaparinux - 36 to 42 hours garlic - don't have to stop ginko - don't have to stop ginseng - don't have to stop warfarin - 4-5 days
Droperidol
Droperidol is a butyrophenone which comes from a different class than ondansetron, dexamethasone, or scopolamine and can be useful in “rescue” situations.
burn patient how should you alter dosing of benzos opioids insulin paralytics
Severe burns lead to hypoalbuminemia which increases the free fraction of many anesthetic drugs including benzodiazepines and opioids. Lower doses of benzodiazepines should be considered, while higher doses of opioids are usually required due to the rapid development of tolerance. Insulin resistance is seen due to increased catecholamine and corticosteroid levels. Proliferation of extrajunctional acetylcholine receptors leads to exaggerated hyperkalemia with succinylcholine use and resistance to nondepolarizing neuromuscular blockers.
Donepezil
Donepezil is a reversible, non-competitive inhibitor of acetylcholinesterase which can cause increased availability of acetylcholine at neuromuscular junctions. Patients on donepezil should be monitored for prolonged relaxation after succinylcholine.
name 3 cholinesterase inhibitors
Cholinesterase inhibitors (donepezil, galantamine, rivastigmine)
Carbamazepine toxicity is associated with
Carbamazepine toxicity is associated with neurologic, cardiovascular, and anticholinergic symptoms. These include mydriasis, nystagmus, QT prolongation, tachycardia, hypotension, flushing, dry mouth, and urinary retention.
Nalbuphine vs Buprenorphine
Nalbuphine: kappa agonist, mu antagonist
Buprenorphine: partial mu agonist, kappa antagonist
M6G side effects:
M3G side effects:
M6G side effects: drowsiness, nausea/vomiting, coma, respiratory depression
M3G side effects: agitation, myoclonus, delirium, hyperalgesia.
1 mg of intrathecal (IT) morphine = x mg of epidural (EP) morphine
1 mg of EP morphine = x mg of IV morphine
1 mg of IV morphine = x mg of PO morphine
1 mg of intrathecal (IT) morphine = 10 mg of epidural (EP) morphine
1 mg of EP morphine = 10 mg of IV morphine
1 mg of IV morphine = 3 mg of PO morphine
