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Pharm II > Lecture 1 > Flashcards

Lecture 1 Flashcards

1
Q

The Sympathetic Nervous System is AKA
The preganglia are near the ________
The postganglia secrete ______

A

Thoracolumbar origin (T1-L2)
spinal cord
norepinephrine

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2
Q

What converts dopamine to norepinephrine?

A

Dopamine beta hyroxylase converts dopamine to NE

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3
Q

Norepinephrine is metabolized by

A

COMT and MAO

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4
Q

The adrenergic receptors are:

A

alpha 1 periphery
alpha 2 central (precedex)
beta 1 heart
beta 2 other smooth muscle

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5
Q

Alpha-1 Postsynaptic Receptor:

A 
Activation increases intracellular calcium
Smooth muscle contraction
Peripheral vasoconstriction
Bronchoconstriction
Inhibits Insulin secretion
Stimulates glycogenolysis and gluconeogenesis
Mydriasis
GI relaxation
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6
Q

Alpha-2 Receptors:

A 
Alpha-2 Receptors:
Presynaptic in the PNS
Decreases entry of calcium into the cell
Limits the release of norepinephrine
Postsynaptic in the CNS
Sedation
Decreased sympathetic outflow
Decreased BP
Platelet aggregation
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7
Q

Beta-1 Postsynaptic Receptor:

A

Beta-1 Postsynaptic Receptor:

Increases HR
Increases conduction velocity
Increases myocardial contractility

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8
Q

Beta-2 Postsynaptic Receptor:

A

Beta-2 Postsynaptic Receptor:

Stimulation leads to smooth muscle relaxation
Peripheral vasodilitation
Decreases BP
Bronchodilitation
Increases insulin secretion
Increases glycogenolysis and gluconeogenesis
Decreases GI mobility

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9
Q

The parasympathetic nervous system is also known as
The preganglia are near ______
The post ganglia secrete _______

A

Craniosacral origin (III, V, VII, X)

Organs of innervation

ACh (Cholinergic)

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10
Q

ACh activates _________

Choline + Acetyl CoA = acetylcholine via ________

ACh is deactivated by _______

A

both arms of the SNS

choline acetyletransferase
(Calcium mediated action potential)

choline and acetate

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11
Q

Cholinergic receptors include

A

Muscarinic and Nicotinic

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12
Q

___________: extended exposure to agonists reduces the number, but not their response. Results in tachyphylaxis.

A

Down regulation

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13
Q

__________: chronic depletion of catecholamines or use of antagonists increases the number of receptors, but not their sensitivity. May account for withdrawal syndrome with beta blockers.

A

Up regulation

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14
Q

Catecholamines are both _________ and ________ that act on the _________ receptors

A

neurotransmitters and hormones

adrenergic

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15
Q

All sympathomimetics are derived from

___________

A

β phenylethylamine.

Presence of hydroxyl groups on the 3 and 4 position of the benzene ring of the β phenylethylamine creates a catachol. (catecholamines)

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16
Q

Pharmacologic effects of sympathomimetics:

A 
Vasoconstriction 
-Cutaneous and renal circulations
Vasodilation
-Skeletal muscle
Bronchodilation
Cardiac stimulation
-Increased heart rate
-Increased myocardial contractility
-Vulnerability to dysrhythmias
Hepatic 
-Glycogenolysis
Liberation of free fatty acids from adipose tissue
Modulation of hormone secretion
-Insulin
-Renin
-Pituitary
CNS stimulation
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17
Q

Synthetic Non-catecholamines:

A

Lack a 3-hydroxyl group
Not metabolized by COMT
Dependent on MAO for metabolism
Metabolism is often slower than that of catechols
Inhibition of MAO may prolong their duration of action.
Patients on MAO inhibitors may manifest exaggerated responses when treated with synthetic non-catecholamines.

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18
Q

Non-cardiac effects of vasoconstrictors:

A

Bronchodilate
Glycogenolysis
Insulin, renin, pituitary hormone
CNS stimulation (low lipid solubility)

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19
Q

Contraindications/Complications of vasoconstrictors:

A

Can worsen LV Failure
Can exacerbate RV Failure
Can decrease renal blood flow
Can mask hypovolemia

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20
Q

Natural catecholamines include

A

Epinephrine
Norepinephrine
Dopamine

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21
Q

Epinephrine stimulates

A

Stimulates Alpha-1, Beta-1, and Beta-2 receptors
Most potent activator of Alpha-1 receptors
2-10X more potent than NE

22
Q

Effects/ Side effects of Epinephrine:

A

Decreases renal blood flow even in the absence of changes in systemic BP.
Decreased SVR
Maintains MAP
Increased HR/ Contractility/ CO
Increased automaticity, increased risk for dysrhythmias
Reflex bradycardia may occur

Side Effects and Monitoring
No CNS effects
Hyperglycemia, mydriasis, platelet aggregation, sweating, headache, tremor, nausea, arrhythmias
Monitor BG, RR, O2 sats, HR, BP

23
Q

Norepinephrine receptors:

A

Primarily an Alpha-1 agonist
Beta-1 effects are overshadowed by its Alpha-1 effects
Beta-2 effects are minimal

24
Q

Effects/ Side Effects of Norepinephrine:

A

Responsible for maintaining BP by adjusting SVR
Increases systolic, diastolic, and mean arterial pressure
Cardiac output may increase at low doses,
Higher doses C.O. may decrease because of increased afterload and baroreceptor-mediated reflex bradycardia
Refractory hypotension
May decrease renal blood flow and cause oliguria
May lead to mesenteric infarct
Peripheral hypoperfusion can lead to gangrene of digits

25
Q

Dopamine receptors:

A

Beta and Alpha Receptor Effects
(10-20 mcg/kg/min)
Over 5mcg/kg/min causes NE to be released contributing to cardiac stimulation (precursor)
Over 10 mcg/kg/min Alpha effects start to predominate
Alpha Receptor Effects
(>20 mcg/kg/min)

26
Q

Dopamine Effects/ Side Effects:

A 
No effect on pulmonary status
Dopamine in the CNS
Inc: mania
Dec: Schizophrenia, ADHD, PD
D2 inhibition- dec prolactin secretion
Monitor BP, HR, MAP, urine output, mental status
27
Q

Ephedrine receptors:

A

Direct and Indirect actions
Principle effect by stimulating the release of NE
Works at Alpha-1 and Beta receptors
Beta stimulation may evoke arrhythmias, particularly in sensitized myocardium

28
Q

Ephedrine Effects/ Side Effects:

A

Principle mechanism is increased myocardial contractility
-Venoconstriction greater than arteriolar constriction increases preload and with increased heart rate and myocardial contractility, increases cardiac output (Beta-1 receptor action)
-Increases Systolic and Diastolic BP as a result
Tachyphylaxis can occur
Preserves or increases uterine blood flow
Bronchial smooth muscle relaxant

Side Effects and Monitoring
HTN, insomnia, urinary retention, headache, weakness, tremor, palpitations, psychosis
Supportive therapy with extravasation/OD
Monitor BP, pulse, urine output, mental status

29
Q

Phenylephrine receptors:

A 
Synthetic Non-Catecholamine
Direct Alpha-1 agonist 
Increases preload > afterload
Small Beta-1 effect
Increases PVR when CO is adequate
May be used to improve coronary perfusion pressure  without chronotropic side effects.
Ok to use in pregnant patients
30
Q

Phenylephrine Effects:

A

Increases preload > afterload
Increases PVR when CO is adequate
May be used to improve coronary perfusion pressure without chronotropic side effects.
Causes reflex bradycardia
Decreases renal and splanchnic blood flow
Increases pulmonary artery resistance and pressure
No dysrrhythmias as a direct effect
Reverses R to L shunt in Tetrology of Fallot

31
Q

Posterior Pituitary Hormones include:

A

Arginine Vasopressin (AVP or ADH)
DDAVP (Desmopressin)
Oxytocin (Pitocin)

32
Q

Vasopressin has _____ effects and ______ effects

A

vasopressor and antidiuretic

Stimulates vascular V1a receptors causing intense arterial vasoconstriction.
In the renal-collecting ducts increases the permeability of cell membranes resulting in the passive reabsorption of water (V2 effect).

33
Q

Unlike catecholamines, the effects of arginine vasopressin are preserved during times of _______ and _________

A

hypoxia and severe acidosis

34
Q

The advantages of vasopressin over epinephrine:

A

Advantages over Epinephrine:
Epi increases myocardial oxygen consumption
Contribute to risk of developing post-resuscitation MI and arrhythmias

Catecholamines may not work well in an acidic environment associated with CPR

In animal studies, vasopressin associated with:
Better blood flow to vital organs
Better delivery of cerebral oxygen
Better chance of resuscitation and better neurologic outcome
HUMAN DATA IS LACKING

35
Q

Is vasopressin a reasonable alternative to epinephrine in the treatment of cardiac arrest?

A

YES!
Vasopressin is at least as effective as Epi, may have fewer adverse effects than Epi., and therefore is a reasonable alternative to Epi. in the treatment of cardiac arrest.

36
Q

Adverse Effects/ Drug interactions of Vasoconstrictors:

A

Adverse Effects/Drug Interactions:

Cardiac dysrhythmias (Beta stimulation)
Pure alpha agonists can activate baroreceptor reflex-mediated bradycardia and possibly decrease CO
Antihypertensives may decrease the pressor response to indirect acting drugs or enhance the response to direct acting drugs (denervation hypersensitivity).

37
Q

Drug interaction of Vasoconstrictors and tricyclic antidepressants/ MAO inhibitors:

A

Tricyclic antidepressants and MAO Inhibitors:
Increase the availability of endogenous norepinephrine.
Exaggerated response with indirect acting agents
Worse in the first 14-21 days of therapy (then a down regulation of receptors occurs)
OK to continue these drugs in the perioperative period
Use a decrease dose of direct acting drugs

38
Q

Drug Interaction of Vasoconstrictors and Cocaine:

A

Cocaine:
Interferes with re-uptake of catecholamines . Both exogenous and endogenous catecholamines exhibit enhanced effects.
Produces central and peripheral sympathetic stimulation, resulting in vasoconstriction, tachycardia, and potentially, arrhythmias.
Acute toxicity may best be managed with adrenergic blockade. (Labetalol with alpha and beta effects

39
Q

Drug interactions of vasoconstrictors and ma huang (ephedra):

A

Natural weight loss products may contain ma huang (ephedra)
Ephedra contains ephedrine, psuedoephedrine

Long term use results in tachyphylaxis from depletion of endogenous catecholamine stores and may contribute to perioperative hemodynamic instability and cardiovascular collapse.

Stop product at least 24 hours prior to surgery.

40
Q

What is phentolamine?

A

Extravasation: Phentolamine

alpha 1 and 2 antagonist
Peripheral vasodilator
Treats skin necrosis secondary to norepinephrine, dopamine, and epinephrine

41
Q

Idiopathic HTN is approximately _____% of HTN. It is related to _________

A

Idiopathic Hypertension (95%)

Related to overactivity of the ANS and an interaction with the Renin-Angiotensin System along with factors related to sodium homeostasis and intravascular volume.

Renin-Angiotensin System is important in control, but not development

42
Q

Idiopathic HTN develops initially from ______

A

Initially, increased BP due to increased CO, (SVR normal)
SVR increases to prevent the increased BP from being transmitted to the capillary bed where it would affect cell homeostasis

43
Q

Perioperative HTN may be the result of ______

A 
Inadequate anesthesia
Airway manipulation
Hypercarbia
Hypoxia
Medications
Aortic cross clamp
Hypervolemia
Hypothermia
Pain
Pre-existing disease states:
-Pheochromocytoma
-Hyperthyroid
-Autonomic hyperreflexia
-Malignant hyperthermia
-Intracranial hypertension
-Renal disease
-Poorly controlled hypertension
Type of procedure being performed
44
Q

The primary cause of perioperative HTN is

A

Primary cause: Increased sympathetic discharge with systemic vasoconstriction

45
Q

Complications of perioperative HTN include:

A

CVA, MI, ischemia, LV dysfunction, arrhythmias, increased suture tension, hemorrhage, pulmonary edema, cognitive dysfunction

46
Q

Vasodilator mechanisms of action include:

A

Direct smooth muscle dilatation
Production of intracellular NO (SNP and nitrates)
Calcium channel blockers
Alpha-1 Antagonists (prazosin and labetalol)
Alpha-2 Agonists (clonidine, alpha-methyldopa)
A.C.E. inhibitors (captopril and enalapril)

47
Q

The hemodynamic effects of vasodilators:

A

Act primarily to cause systemic vasodilation
Pure arteriole dilator causes minimal effect on preload.
“Pure” venodilators are not available. NTG acts primarily on the venous circulation, but also affects arterioles.
Balanced vasodilator (SNP) decreases afterload and preload.

48
Q

Hemodynamic effects of pulmonary vasodilators:

A

Pulmonary Vasodilators
Inhaled NO may be only “pure” pulmonary vasodilator
PGE1 is excellent pulmonary vasodilator, but also causes systemic hypotension requiring NE to maintain systemic BP

49
Q

Vasodilators have a reflex increase in _______ and a redistribution of __________.

A

HR
coronary blood flow

Hemodynamic Effects:
Reflex increase in HR (Baroreceptors)
Redistribution of coronary blood flow
NTG may improve collateral circulation
Others may cause coronary steal
50
Q

70-90% of the coronary artery perfusion to the LV occurs during __________

Aortic diastolic pressure governs _________

In the presence of ischemic heart disease, the collateral arteries are maximally dilated and coronary perfusion is largely ______________

A

diastole

perfusion

pressure dependent

51
Q

__________: Narrowed coronary arteries are always maximally dilated to compensate for the decreased blood supply. Dilating the other arterioles causes blood to be shunted away from the coronary vessels.

In the myocardium, SNP dilates both epicardial conductance and intramyocardial resistance vessels and in the presence of CAD, shunts blood away from ischemic zones.

NTG preferentially dilates conductance vessels and directs more blood toward ischemic zones.

A

Coronary Steal

Pharm II (3 decks)

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