Lecture 10 (Exam 2) - MAGA Brooke's Deck Flashcards
What enzyme catalyzes the synthesis of prostaglandins?
COX (Cyclooxygenase)
Slide 33
This form of COX is responsible for gastric protection, hemostasis, and renal function…
COX-1
Slide 33
Hemostasis (produces thromboxane)
Renal function (IDK)
COX-1 or COX-2?
Ubiquitous,
“physiologic”
Inhibition of this enzyme is responsible for many adverse effects
COX-1
Slide 33
COX-1 or COX-2?
Pathophysiologic, expressed at sites of injury, not protective
COX-2
Slide 33
COX-2 is responsible for which symptoms?
Pain, inflammation, and fever
Slide 33
What are the three main properties of NSAID drugs?
Analgesic
Anti-inflammatory
Antipyretic
Slide 34
Are drugs below non-specific or COX-2 selective? What GI symptom may occur?
Ibuprofen, naproxen, aspirin, acetaminophen, and ketorolac
Non-Specific
Increased gastric irritation with these drugs
Slide 34
Multimodal includes S____-a ____ acting anesthetics agents and O______ sparing components.
short acting; Opioid sparing.
slide 2
Celecoxib (Celebrex), Rofecoxib (Vioxx), Valdecoxib (Extra), Parecoxib (Dynastat) are all examples of what?
COX-2 Selective NSAIDs
Slide 34
Do COX-2 selective NSAIDs effect platelets?
NO
Slide 35
Because COX-2 selective NSAIDs have no effect on platelets, that increase the chance of what two disease processes?
MI and CVA
Slide 35
COX-2 selective and COX-nonspecific inhibitors have _____________ analgesia
Comparable
Slide 35
What was the first COX-2 inhibitor that decreases PG synthesis?
Celecoxib (Celebrex)
Slide 36
What is the dosage for Celebrex?
200 to 400 mg PO QD
Slide 36
Celebrex reaches its peak in…
3 hours
Slide 36
Define non-opioid anesthesia. List some alternatives to treat pain.
PT & OT, Chiropractic care, acupuncture, massage, yoga, weight loss, cold/heat, OTC medications, TENS unit…etc.
slide 11-12
What is the pain response pathway? (5)
slide 17
(this was in the pain pathway slide set too)
What are the 2 classes of opioids?
1) Phenanthrenes (L-isomers have opioid activity; morphine, codeine)
2) Benzylisoquinolones (Lack opioid activity; Papaverine, noscapine)
slide 19
What drug class does Ondansetron fall into?
It is the first 5-HT3 antagonist
-It was approved for CINV
-Responsiveness decreased by variations in the CYP2D6 activity!
(Slide 51)
Ondansetron is equivocal to what two drugs?
Droperidol & Metoclopramide
(Slide 51)
What are the side effects of Ondansetron?
- HA
- Constipation and
- Some QT prolongation
(Slide 51)
What is the duration & dose of Ondansetron? How about pediatric dose?
Duration/plasma half life is 4 hours!
Dose: Adults: 4 mg IV (up to 8 mgs)
Dose: Pediatrics: 0.1 mg/kg IV
(Slide 51)
What is the MOA of Corticosteroids?!
Why are Corticosteroids used with 5-HT3 (Ondansetron) & droperidol?
Hint: It was studied in CINV!
MOA is unknown: It works on glucocorticoid receptors in Nucleus Tractus Solitarius (NTS)!
Corticosteroids increase effectiveness for 5 HT3 antagonists and droperidol!
(Slide 52)
What is the dose for Dexamethasone (Decadron)?!
What is the MOA of Dexamethasone (Decadron)?
8 to 10 mgs
MOA: Anti-inflammatory; inhibition of phospholipase and cytokines and stabilization of cellular membrane.
(Slide 53)
What is the delay of onset of Dexamethasone (Decadron)?
Are there any adverse effects of a single dose of Dexamethasone (Decadron)?
Delay in onset is 2 hours! Efficacy persists for 24 hours!
With diabetics one dose will not throw off their blood sugar levels.
If you push it to fast you are going to give them Spicy Butthole 🥵and your patient will be mad!
(Slide 53)
According to the TXWES medication guide, what are the single doses/frequency for Acetaminophen (Ofirmev), Ketorolac (Toradol), & Ibuprofen (Caldor). What is are their Max daily?
Slide 62
A 50 y/o, 60 kg female patient received a Lidocaine initial dose of 1 mg/kg with a subsequent infusion of 1.5 mg/kg/hour for 1.5 hours. How much total Lidocaine in mgs did she receive in the PACU?
60kg x 1 mg/kg = 60 mg
60 kg x 1.5 mg/kg = 90 mg (1 hour)
(60 kg x 1.5mg/kg = 90 mg)/2 = 45 mg (30 minutes)
60+90+45 = 195 mg total!!!
(Slide 59)
What kind of properties does propofol have?
Analgesic properties
Slide 42
Ketamine inhibits N_____ activation.
NMDA
Slide 42
(We do not need to know TEAMHealth Formula in this slide)
What is the induction dose of Ketamine for IV and IM?
0.5-1.5 mg/kg/IV
4-8 mg/kg IM
Slide 43
What is the maintenance dose of Ketamine for IV and IM?
0.2-0.5 mg/kg IV analgesia
4-8 mg/kg IM
Slide 43
What is the subanesthetic (analgesic dose) of ketamine?
0.2 -0.5 mg/kg IV
Slide 43
What is Post op sedation and analgesia dose for ketamine?
1-2 mg/Kg/hour (pediatric cardiac surgery)
Slide 43
What is neuraxial analgesia dose of Ketamine?
30mgs Epidural
5-50 mg in ml of saline intrathecal/spinal/subarachnoid.
Slide 43
which concentration lidocaine do we use as CRNA?
A bag of 2g lidocaine with concentration of 4mg/ml.
Slide 44
Multidose lidocaine vial is used for _____.
infiltration or peripheral nerve block.
Slide 44
Lidocaine is ______Local anesthetic.
Amide (amides anesthetics have 2 “i”s)
Except for cocaine. Cocaine is also local amide anesthetic.
Slide 45
How is lidocaine metabolized?
liver
Slide 45
what is the dose of lidocaine?
1 to 2 mg/kg IV (initial bolus) over 2-4 min.
1 to mg/kg/hr (drip intraop)
terminated 12-72 hours.
Slide 45
Regarding Gabapentin’s preemptive analgesia, What 3 studies/type of procedures is it used in?
Spine surgeries
Orthopedic procedures
major abdominal procedures.
(slide 27)
What is the PO dose of preemptive Gabapentin?
When should we give it?
What is it’s MOA?
300-1200mg PO
1-2 hrs prior to OR
GABA analogue
(slide 27)
For Preemptive Gabapentin, what patient population is it contraindicated for?
MG and Myoclonus
- reduce dose in elderly
(slide 27)
What are Gabapentin’s side effects?
- Somnolence
- fatigue
- ataxia
- vertigo
- GI disturbances: constipation
- seizures in abrupt withdrawal in seizure pts (when Gaba is used as an antiepiliptic)
- Weight gain
(slide 29)
For Ofirmev, what is the:
- Dose/Frequency
- Peak effect time (PO & IV)
- Duration
Slide 38
What is the MOA for Ofirmev?
Reduces prostaglandin metabolites
Slide 38
What is the absolute contraindication for Ketorolac per Castillo?
Anaphylaxis reaction
Slide 40
For Ketorolac, what is the MOA, Peak effect time, and Dose
MOA: Inhibits COX-1 and -2 and prevents PG synthesis
Peak: 45 to 60 minutes IV
Dose: 15 to 30mg q6h (1/2 dose in elderly)
Max Dose: 60-120mg QD
Slide 40
What are some contraindications to consider when giving Toradol?
Severe Renal impairment
Risk for bleeding
CAD
CABG
Pregnant
Elderly (decrease dose)
NSAID allergy
Slide 40
Lidocaine plasma concentration of ____ causes what?
1-5 mcg/ml = ?
5-10 mcg/ml = ?
1-5 = analgesia
5-10 = Systemic HYPOtension, myocardial depression, circum-oral numbness; tinnitus; skeletal muscle twitching
(slide 46)
Lidocaine plasma concentration of ____ causes what?
10-15 mcg/ml = S____ & U_____
15-25 mcg/ml = A____ & C_____
These are OD levels
10-15 = Sz’s; unconsciousness
15-25 = apnea (affects pons and medulla oblongata) & coma
(slide 46)
Lidocaine plasma concentration of ____ causes what?
> 25 mcg/ml
Cardiovascular depression!!!! (lipid rescue stat!)
(slide 46)
Which procedure would you expect to see a high use of Lidocaine?
(HINT: Castillo mentioned this)
EGD’s
Castillo gives a “boatload” of lidocaine in EGD’s
(per Castillo)
You’re administering Lidocaine gtt to Castillo’s mom so she can have a Naples-ectomy. What should you warn mother Castillo about?
You will hear a ringing sound (tinnitus), don’t answer it. HAHAHAHAHAHAHAHAHAHAHAHA SO FUNNY 😑
Also will taste a metallic taste
(Our torturer)
If we give Lido w/ Epi, should the dose be higher or lower?
Why?
Higher, because the epi will vasoconstrict and “keeps the lidocaine more in place, [therefore] lesser intravascular, lesser s/e, lesser chances of OD”
(Castrater)
Scene:
It’s been a long day. You’re on your 8th sloppabotomy of the day and no one has come to lunch you. Suddenly, Arthur the hasty CRNA steps in and offers you a break. Despite knowing better you cave and allow him to lunch you.
30 mins later, you enter the OR to find the surgery team doing compressions on your pt. You look at Arthur and ask what happened? His response is “dude, she coughed so all I did was throw her lidocaine drip wide open and now her heart stopped”. You look at the lido gtt which is empty and know the pt got the full bottle.
WHAT DO YOU DO?
Lipid rescue!!!! and don’t stop compressions until you administer the whole dose (whatever it may be)
Also kick Arthur in the nads
(Castillo’s ethical dilemma)
Which pt’s do we give Magnesium to most often?
OB - eclampsia
(C mentions during slide 47)
This med(electrolyte) has anti-nociceptive effects by antagonizing the NMDA receptor and “probably” potentiates opioids centrally and peripherally
Magnesium
(slide 48)
Mg++ regulates what?
(HINT: 4)
- Ca++ access into & action within cell
- Neurotransmission
- Cell signaling
- Enzyme function
(slide 48)
Mg++ has L_______ passage across the __ __ __.
C/I for Mg++ include M________ G______ and R_____ failure
limited; BBB
Myasthenia Gravis and Renal failure
(slide 48)
What S/E should we monitor for with Mg++?
Hypotension, bradycardia, ataxia, somnolence, delayed movement, ⬇️ muscular tone
(slide 49)
Mg++ dosing:
Preop:
Intraop:
Preop: 50 mg/kg IV
Intraop: 8 mg/kg/hr IV
(slide 49)
Mg++ significantly reduces the amount required for which opioid?
Fentanyl
(slide 49)
Ibuprofen:
MOA
Contraindications
Dose
Peak
Excretion
Slide 41
Using multimodal anesthesia, what 2 meds might we give in preop to better control pain later?
Acetaminophen 1000 mg PO, Gabapentin 300 mg PO (slide 23)
With non-opioid anesthesia, what medications are used for induction?
Propofol, Lidocaine, Ketamine, volatile anesthetics. Paralytic if needed. (Slide 23)
With multimodal anesthesia, what meds might you give during the intraop period?
IV Tylenol aka Ofirmev 1g, esp if pt did not receive PO Tylenol in preop.
Propofol, lidocaine, ketamine, volatile anesthetics.
Magnesium infusion - per tx wes ref this is 8 mg/kg/hr cont gtt
Ondansetron, Dexamethasone, Ibuprofen IV, Toradol (slide 23)
What meds are given post op to control pain using multimodal anesthesia?
PO dosing of Tylenol, Magnesium, Gabapentin, Celebrex or Advil. Per chart on slide 23:
-Tylenol 1000mg
-Mag 400 mg BID
-Gabapentin 300 mg TID
-Celebrex or advil TID with surgeon’s permission
What is the MOA of gabapentin?
Block VG Ca channels, inhibits release of glutamate and excitatory neurotransmitters, enhances descending inhibition. (Slide 25)
Is gabapentin lipid soluble? How much does it like proteins? What’s it’s E 1/2 time?
Yes Lipid soluble ✅
NOT protein bound ❌
Brief E 1/2 time
(Slide 25)
Does gabapentin have any drug-drug interactions?
NO! It’s friendly with other drugs 😊 (slide 25)
What are indicated uses for gabapentin?
- Seizures
- Neuropathic pain
- Chronic pain syndromes
Chronic pain = diabetic neuropathy, post herpetic neuralgia, reflex sympathetic dystrophy, phantom limb pain, fibromyalgia. (Slide 26)
Which two opioid receptors cause physical dependence
Mu-2 and Delta
Which 2 opioid receptors have low potential for abuse?
Mu-1 & Kappa
Which 2 opioid receptors cause miosis?
Mu-1 and Kappa
Which 2 opioid receptors cause constipation? One more than the other.
Mu-2 - marked
Delta- minimal
Which 2 opioid receptors are stimulated by endorphins, morphine, and synthetic opioids?
Mu-1 & Mu-2
Which opioid receptor is stimulated by dynorphins?
Kappa
Which opioid receptor is stimulated by enkephalins?
Delta
Which opioid receptor causes diuresis?
Kappa
Which opioid receptor cause bradycardia, hypothermia, and urinary retention?
Mu-1
Which opioid receptor is primarily concerned with spinal anesthesia, not so much supraspinal?
Mu-2
Which 2 opioid receptors cause ventilatory depression?
Mu-2 and Delta
Which of the opioid receptors causes euphoria?
Mu-1
Which of the opioid receptors causes dysphoria and sedation?
Kappa
