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Spring '20/ L. PHARM TEST 2 - opioids, anticholinergics, cholinesterase > IV SEDATIVES AND HYPNOTICS (PP+Notes) > Flashcards

IV SEDATIVES AND HYPNOTICS (PP+Notes) Flashcards

1
Q

Barbiturates

how fast?

A

rapid onset and rapid awakening

Short-acting: thiopental, methohexital, thiamylal

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2
Q

Barbituates Mechanism of action

A

Depress the Reticular Activating System (RAS)

Hypoproteinemia intensifies the response to barbiturates because the free fraction of drug is increased, causing more to diffuse from blood to brain

potentiating GABAa channel activity, functions allosterically to increase the affinity of gaba for its binding site increasing the duration of the gaba

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3
Q

Barbiturates PH? Lipid soluble?

A

High pH; drug dissolved in low pH solution should not be mixed with thiopental to avoid precipitation

Lipid soluble, 60% unionized in plasma—good entry into the brain; rapid onset

Methohexital has prominent excitatory effects—hiccups, seizures

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4
Q

Thiopental -vascular and intracranial effects? power point

good for seizures?

A

Anticonvulsant and amnestic actions

Increases cerebral vascular resistance; decreases cerebral blood flow and intracranial pressure; decreases cerebral metabolism
Drug of choice in head injury

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5
Q

Thiopental and pain control?(PP)

A

Poor analgesic; may be hyperalgesic

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6
Q

Thiopental and Histamine? (PP)

A

May cause histamine release (avoid in severe asthmatics)

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7
Q

Thiopental and contraindications (PP)

A

Contraindicated in patient with porphyria

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8
Q

Thiopental and Respiratory and cardiac system (pp)

A

Depresses respiratory system, myocardial contractility

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9
Q

Why is thiopental is mixed and stored in a solution with pH = 10-11? (PP)

A

To keep thiopental in ionized form. Ionized form is more water soluble. A precipitate will not from when thiopental is stored in a solution with a high pH

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10
Q

Thiopental (BOOK) induction dose requirements

A

vary with patient age, weight, and most importantly cardiac output.
the dose should decrease with age
dose needed for anesthesia in early pregnancy is decreased 18%
requirements are higher in children 1 year post thermal injury.

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11
Q

Methohexital (BOOK) and seizures?

A

effective in inducing seizures. useful during electroconvulsive therapy.
disadvantage is myoclonus.

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12
Q

Propofol (PP) MOA & recovery?

A

Acts on GABA and glycine receptors
Quicker, better recovery than with the barbiturates
Most important advantage—more rapid and complete awakening

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13
Q

Propofol cardiac changes

PP

A

Causes greater decrease in BP than thiopental (decrease in CO and SVR); HR often unchanged; may have sympatholytic or parasympathomimetic action

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14
Q

Propofol Respiratory (PP)

A

More profound ventilatory depressant than thiopental

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15
Q

Propofol antiemetics properties ?

pruritic?

analgesic effects?

anticonvulsant effect?

cerebral blood effects?
(PP)

A

Antiemetic properties— chemoreceptor trigger zone (CTZ) and vomiting center action

Antipruritic

No analgesic effects

Anticonvulsant

Decreases cerebral blood flow and metabolism

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16
Q

Propofol preparations considerations BOOK

A

increases triglyceride,

supports bacterial growth.

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17
Q

what is different about propofol and spinal motor neuron excitability? (book)

A

in contrast to volatile anesthetics, spinal motor neuron excitability is not altered by propofol suggesting that immobility during propofol anesthesia is not caused by drug induced spinal cord depression.

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18
Q

propofol metabolism (book)

A

metabolized by p450 and excreted by the kidneys. no evidence of delayed clearing in patients with cirrhosis.

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19
Q

propofol lungs uptake? (book)

A

pulmonary uptake of propofol is significant and influences the initial availability of propofol. most of the drug that undergoes pulmonary uptake during the first pass is released back into the circulation

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20
Q

Propofol induction children and elderly (BOOK)

A

children require higher doses elderly require lower induction dose

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21
Q

propofol conscious sedation dose?

A

25-100mcg/kg/min

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22
Q

propofol maintenance of anesthesia dose

A

100-300mcg/kg/min

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23
Q

propofol antiemetic dose?

A

10-15mg IV in pacu

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24
Q

Propofol cardiac dry old people. tell me about this.

A

exaggerated in hypovolemic patients, elderly patients and patient with compromised left ventricular function.

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25
Q

what does propofol block the stimulation of? (think airway)

A

stimulation produced by direct laryngoscopy and intubation of the trachea reverses the blood pressure effects of propofol.

also blunts the hypertensive response to placement of laryngeal mask airway.

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26
Q

propofol

hepatic and renal function,

eye pressure,

coags?

A

green urine

decreases intraocular pressure

no alter of coags

risk of brady cardia- give epinephrine

27
Q

propofol lactic acidosis

A

propofol infusion syndrome metabolic acidosis. doses exceeding 75mcg/kg/min

28
Q

Benzodiazepines moa (pp)

A

Enhance actions of GABA lead to increase entry of Cl- leads to hyperpolarization

Short-acting: diazepam, lorazapam, midazolam

29
Q

Benzodiazepines used for?(pp)

A

Antianxiety, amnestic, sedative, hypnotic, anticonvulsant; muscle relaxation

Poor analgesics

30
Q

benzodiazepines (pp) cardiac effects

A

Little effect on CV system unless patient is hypovolemic—profound hypotension

31
Q

benzodiazepines (pp) cerebral effects

A

Cause cerebral vasoconstriction—lowers cerebral blood flow, metabolism and intracranial pressure

32
Q

benzodiazepines (pp) soluability?

A

Diazepam is poorly water soluble; dissolved in organic solvent and pain may occur on injection

33
Q

protein bound of diazepam %? (pp)

A

98-99%

34
Q

Epidural placement considerations (in class discussion)

A

GIVE FLUIDS! some will not put in an epidural until they have had a liter of fluids

35
Q

Benzodiazepines side effects BOOK

name the synergistic effects with various drugs?

A

fatigue and drowsiness are most common side effects antacids decrease absorption impairment of cognitive function. anterograde amnesia-especially if there is concomitant ingestion of ETOH. Synergistics effects with ETOH, inhaled and injected anesthetics opioids and alpha 2 agonists.

36
Q

Ketamine (pp)

A

Produces amnesia and profound analgesia by interacting with NMDA-type glutamate receptor

Cerebral vasodilator— increases cerebral blood flow and metabolism and increases intracranial pressure
Contraindicated in head injury

Causes hypertonus and nystagmus

Stimulates SNS—CV enhancement (increased HR, CO, bp)

IV or IM

37
Q

Ketamine in class discussion

A

Never give ketamine unless your on the way to the or

Give versed as it will relax the patient. Don’t give with dementia, ptsd, if they start having flashbacks give more versed

If you know the patient has ptsd or they are a young buck 18-19 year old kids- they get wild when they wake up. Move them over to the bed, put your rails up, then wake them up.

Deep extubate if they don’t have any contraindications.

Hypertonus- tense muscles, ridged, nystagmus- eyes are going twitchy.

Im- pediatric patients. Mentally retarded, psychiatric issues- im ketamine calms them down. If someone is already wild you need to IM them

Higher icp- infarct the brain. They can’t play the piano anymore

Severe dreams hallucinations nausea and vomiting

38
Q

ketamine who is a poor candidate? (pp)

A

Poor risk patients are candidates for ketamine

Avoid in cardiac patient, glaucoma patient, patient with elevated ICP

Emergence is severe; dreams, hallucinations, N/V

Weak base; do not mix with alkaline solutions

39
Q

Versed BOOK pharmacokinetics

A

rapid absorption from the GI tract and prompt passage across the blood brain barrier. extensively bound to plasma proteins

40
Q 
versed metabolism (book)
what drugs will slow the metabolism of this drug
A

hepatic ally metabolized. metabolism is slowed in the presence of cimetidine, erythromycin calcium channel blockers an anti fungal drugs. that inhibit p450. really excreted and not altered by renal failure.

41
Q

versed central nervous system (book)

A

potent anticonvulsant effects. produces decreases in CMRO2 and cerebral blood flow comparable to barbiturates and propofol.

42
Q

versed ventilation (book)

A

dose dependent decreases in ventilation by decreasing hypoxic drive. COPD- even greater respiratory depression. transient apnea may occur after rapid injection of large doses of midazolam. decreases upper airway activity and swelling reflex

43
Q

versed cardiovascular system (book)

A

induction dose create a decrease in systemic blood pressure and increase in heart rate. cardiac output not effected. decrease in bp is due to decrease in SVR.

44
Q

versed sedation dose, onset, peak, and duration.

A

1-2.5mg iv onset 60 seconds peak 5 minutes duration 80 minutes.

45
Q

versed induction of anesthesia

A

0.1-0.2mg/kg iv over 30-60 minutes synergistic interaction is facilitated when a small dose of opioid

46
Q

flumazenil dose? onset? peak? duration?

A

0.2-1mg IV give additional doses up to 3mg in 1 hour. duration of action is 30-60 mimutes. RESEDATION MAY OCCUR!

47
Q

flumazenil and antieliptics drugs

A

administration to patients being treated with anti epileptic drugs for control of seizure activity is not recommended as it could precipitate acute withdrawal seizures.

48
Q

Scopolamine (Hyoscine) & indications

A

competitive ACH antagonist at muscarinic receptor. prevent and create N&V motion sickness amnesia sedation or vagolysis. greater antisialagogue and ocular effects that does atropine with lesser effects on the heart.

49
Q

Scopolamine onset

A

apply one patch the evening before surgery or 1 hour before cesarean section. effects within 4 hours and last for 72 hours

50
Q

scopolamine reversal

A

pyridostigmine 15-60mg/kg

51
Q

scopolamine adverse effects

A

hallucinations, delirium, tachycardia drowsiness restlessness, confusion, anaphylaxis increased intraocular pressure decreased sweating.

52
Q

scopalamine precautions

A

children and elderly more suspectable to adverse effects. contraindicated in acute angle glaucoma, patients unable to tolerate tachycardia.

53
Q

scopolamine on the eye

A

produces mydriasis and cycloplegia

54
Q

Etomidate dose

A

0.2-0.4mg/kg
onset 1 minute
duration 10min

55
Q

Etomidate contraindications

A

adrenocortical suppression.

56
Q

etomidate metabolism

A

metabolized by hydrolysis in the liver.

57
Q

lorazepam

A

1-2mg max of 4mg
more potent sedative and amnesic than midazolam and diazepam. obesity prolongs the sedative effects of lorazepam duration 6-24hrs.

58
Q

ketamine

A

dissociative anesthesia. resembles a cataleptic state in which the eyes remain open with a slow nystagmic gaze. non communicative though wakefulness may appear present. however frequency of emergence delirium limits the clinical usefulness of ketamine as a sole agent.

59
Q

ketamine binding site

A

NMDA receptor possibly muscarinic receptors??

60
Q

ketamine induction dose

A

1-2mg/kg IV

61
Q

ketamine precautions

A

HTN, coronary heart disease. increased intracranial pressure, history of cerebrovascular accident increased intraocular pressure and psychiatric disorder, it is contraindicated for surgery or diagnostic procedures of the pharynx. use it cautionsly in patients with convulsive disorder.

62
Q

VERSED CONTRAINDICATION

A

GLAUCOMA

63
Q

risk factors for propofol infusion syndrome

A 
propofol greater than 75mcg/kg/min
infusion duration greater than 48hours
children greater adults
inadequate oxygen delivery
sepsis
significant cerebral injury
64
Q

clinical presentation of propofol infusion syndrome

A 
metabolic acidosis
rhyabdomyolysis
enlarged or fatty liver
renal failure
hyperlipidemia
lipemia (cloudy plasma or blood)

Spring '20/ L. PHARM TEST 2 - opioids, anticholinergics, cholinesterase (8 decks)

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