Locals Chart Flashcards

1
Q

trade names of bupivicaine

A
Marcaine
Marcaine Preservative-Free
Marchaine Spinal
Sensorcaine
Sensorcaine-MPF
Sensorcaine- MPF Spinal
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2
Q

how is bupivicaine supplied

A

Racemic mixture @

  1. 25% = 2.5mg/mL
  2. 5% = 5mg/mL
  3. 75% = 7.5mg/mL
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3
Q

what is bupivicaine used for?

A

Subcutaneous
PNB
Epidural
Spinal

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4
Q

Subq dose of bupivicaine and form

A

0.25%

dose 2.5 mg/kg

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5
Q

PNB dose of bupivicaine and form

A

PNB 0.25-0.5%

dose 2.5 mg/kg

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6
Q

Epidural dose of bupivicaine and form

A

Epi: 0.5-0.75%

dose 2mg/kg

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7
Q

Spinal dose of bupivicaine and form

A

Spinal: 0.5-0.75%

dose 0.3 mg/kg

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8
Q

max dose of bupivicaine SUBQ AND PNB SAME!!

A

175mg

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9
Q

max dose of bupivicaine SUBQ AND PNB SAME WITH EPINEPHRINE

A

225mg

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10
Q

what is the MAX DOSE of Bupivicaine Epidural

A

170mg

**5 mg less than Subq and PNB

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11
Q

what is the MAX DOSE of Bupivicaine Epidural WITH EPINEPHRINE

A

225 mg

** this is the SAME as Subq and PNB with epinephrine

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12
Q

MAX DOSE WITH BUPIVICAINE

A

0.3 mg/kg

NO EPINEPHRINE WITH SPINALS

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13
Q

what is the toxic plasma concentration of bupivicaine

A

> 3mcg/mL

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14
Q

Protein binding of bupivicaine?

and what does this mean?

A

96%
LONG duration of action hours
*depends on dose and location for exact time

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15
Q

metabolism of bupivicaine

A

HEPATIC- ALL AMIDES
SLOWEST METABOLISM OF ALL LOCALS

w/etidocain and ropivicain
BER – toxicity risk

Amide Hydrolysis and conjugation

Aromatic hydrozylation
N-dealkylation

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16
Q

half life of bupivicaine

A

3.5 hours

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17
Q

what is the relationship of sensory vs. motor block with bupiviciane

A

sensory block often OUTLASTS motor

sensory- at site

motor 2 below

sympathetic- upto 6 above

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18
Q
duration of action of bupivicaine- why
Subcutaneous
PNB
Epidural
Spinal
A
LONG- because highly protein bound
Subq: 2-8 hours
PNB: 4-12 hr
Epi: 2-5 hr
Spinal: 1-6 hr
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19
Q

Adverse Reactions with Bupivicaine

what MUST you know about this drug?

A

CV- MOST CARDIOTOXIC*****

Binds Na channels- CV arrest, HR block, hypotension, palpitations, Ventricular arrhythmias

CNS: Anxiety, dizziness, circumoral numbness, restlessness, seizure, tinnitus, blurred vision, miosis

GI: N/V

MS: chondrolysis

Hypersensitive, anaphylaxis, itching, angioedema

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20
Q

pKa of bupivicaine and what does this mean?

A

8.1
*same as ropivicaine
intermediate onset

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21
Q

contraindications with bupivicaine

A

0.75% NEVER for OB epidural- CV arrest- difficult to resuscitate

NEVER Bier block- systemic toxicity risk with tourniquet release

Obstetrics- crosses placenta pregnancy category C never while breastfeeding

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22
Q

lipid solubility =

A

potency

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23
Q

protein binding =

A

duration of action

follow VERY far by lipid solubility

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24
Q

how does adding sodium bicarbonate to LAs affect them?

A

alkalinizing LAs
increases the lipophilic portion of Las
more potent- moves into cells faster

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25
Q

the longer the carbon backbone of LAs…

A

the creating the LIPID SOLUBILITY
PROTEIN BINDIN
POTENCY
DURATION OF ACTION

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26
Q

how does adding Epi (1:200,00) affect bupivicaine?

A

decreases blood levels by 10-20%

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27
Q

what conditions increase LAs toxicity

A

metabolic & respiritory ACIDOSIS
decreased SZ threshhold
decreased protein binding

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28
Q

System Absorption Rates of Various Sites

A

In Time I Can Please Everyone But Susie and Sally

IV
Tracheal
Intercostal
Caudal
Paracervical
Epidural
Brachial Plexus
Subarachnoid (Sciatic, Femoral)
Subq
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29
Q

trade name of Lidocaine

A

Xylocaine
Xylocaine-MPF
many topical names

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30
Q

how is lidocaine supplied?

A

0.5% = 5mg/mL
1% (5mL) = 10mg/mL
2% (5mL) = 20mg/mL

4% LTA
5% (2mL) = 50mg/mL
10% 100mg/mL

LTA Kit- 4%

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31
Q

what is lidocaine used for?

A
Topical
Infiltration
IVRA- Beir Block- tourniquet
PNB
Epidural
Spinal
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32
Q

dose of topical lidocaine AND form %

A

Topical – 4%, 4 mg/kg

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33
Q

dose of infiltration lidocaine AND form %

A

Infliltration: 0.5-1% 4mg/kg

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34
Q

dose of IVRA lidocaine

AND form %

A

IVRA: 0.25-0.5%, 4 mg/kg

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35
Q

PNB dose of lidociane AND form %

A

PNM: 1-1.5% 4 mg/kg

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36
Q

epidural dose of lidocaine and form %

A

Epi 1.5-2% 4 mg/kg

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37
Q

spinal dose of lidocaine AND form %

A

Spinal: 1.5-5% 1.5 mg/kg

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38
Q

protein binding of lidocaine and WHAT does that mean?

A

70%
intermediate duration
protein binding most determines duration of action

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39
Q

metabolism of lidocaine

A

Hepatic
HEPATIC- ALL AMIDES

Dealkylation → mono-ethylglycin-exylidide 80% activity of lidocaine as an anti-arrhythmic

To
Hydrolysis → xylidide 10%

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40
Q

onset of lidocaine and WHY

A
FAST
because- pKa 7.7
Etidocaine also 7.7
second only to Mepivacaine 7.6
closest to physiologic pH 
most non-ionized most to cross into cell
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41
Q

1/2 life lidocaine

A

96 min

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42
Q
duration of lidocaine: each route
Topical
Infiltration
IVRA- Beir Block
PNB
Epidural
Spinal
A
Topical: 0.5-3 hr
Infliltration: 0.5-1 hr
IVRA: 0.5-1 hr
PNB: 1-3 r
Epi: 1-2 hr
Spinal: 0.5-1 hr
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43
Q

contraindications with Lidocaine

A
hypersensitivity
Adam Stoke
WPW
severe SA, AV or IV Heart Block
corn-derived dextrose- corn allergy

pregnancy category B

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44
Q

Adverse Reactions with Lidocaine

A

CV collapse, bradycardia, arterial spasm, arrhythmia, increased d-fib threshold, edema, flushing, SA node depression
Pronlonged PR and QRS

CNS: Anxiety, dizziness, circumoral numbness, metallic rest, lethargy restlessness, seizure, tinnitus,
HA, hyper-hypo-esthesia

GI: N/V

Hepatic- hepatic disease increases concentration- decreasing metabolism

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45
Q

use of lidocaine for spinal?

A

declined
d/t
Transient Neurologic Symptoms

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46
Q

what is lidocaine used most often for?

A

IVRA

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47
Q

how does lidocaine IV assist during DL?

A

attenuate increases in IOP,ICP, IAB

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48
Q

Mepivacaine trade names

A

Carbocaine

Polocaine

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49
Q

uses of mepivacaine

A

Infiltration
PNB
Epidural
Spinal

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50
Q

how is Mepivacaine supplied

A

1% (10mg/mL)
2% (20mg/mL)
Genergic 3% (30mg/mL)

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51
Q

Infiltration dose of mepivacaine :

A

0.5-1% 5 mg/kg

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52
Q

PNM: dose of mepivacaine

A

1-1.5% 5 mg/kg

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53
Q

Epi: dose of mepivacaine

A

1.5-2% 5 mg/kg

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54
Q

Spinal: dose of mepivacaine

A

2-4% 1.5 mg/kg

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55
Q

% protein binding of mepivacaine and what does that mean?

A
78%
DURATION
Intermediate
Lidocaine is 65%
Bupivicaine is 94%
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56
Q

1/2 life of mepivacaine

A

1 hour

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57
Q

metabolism of mepivacaine

A

AMIDE

Hepatic

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58
Q

onset of mepivacaine and what that mean?

A
FAST 
dose dependent
3-20 minutes
pKa 7.6 FASTEST!!
7.7 for lido and etido
close to physiologic pH- non-ionized portion greatest crosses lipid layer of neuron
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59
Q

Duration of each route of mepivacaine: and why

Infiltration:

PNM: 2-4

Epi

Spinal

A

intermediate because 76% protein bound
Infliltration: 1-4 hr

PNM: 2-4 hr

Epi 1-3 hr

Spinal1-2 hr

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60
Q

how are locals excreted?

A

amides- renal

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61
Q

adverse runs with mepivacaine

A

CV collapse, bradycardia, arrhythmia, edema, flushing,

CNS: Anxiety, dizziness, circumoral numbness, metallic rest, lethargy restlessness, seizure, tinnitus,
Blurred vision, miosis

GI: N/V, fecal incontinence

Resp: RD, arrest, hypoventilation

Hepatic- hepatic disease increases concentration- decreasing metabolism

MS- intra-artricular infusion related chondrolysis

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62
Q

WHAT is unique about Mepivacaine?

A

it does NOT cause vasodilation!

do NOT add epinephrine to this drug!

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63
Q
max dose mepivacaine
infiltration
PNB
EPI
Spinal
A
MAX DOSE:
Infliltration: 400 mg
PNB: 400mg
Epi: 400 mg
Spinal 100mg
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64
Q

max dose of lidocaine

A

300 mg for ALL except spinal

65
Q

max dose of lidocaine with EPINEPHRINE

A

500 mg with Infiltration, PNB, Epidural

66
Q

which forms is epinephrine NOT added with

A

Topical
IVRA
Spinal

67
Q

contraindications of mepivacaine

A

Pregnancy Category C

hypersensitivity to AMIDES

68
Q

trade name of Prilocaine

A

citanest

69
Q

principal clinical uses of Prilocaine

A
Infiltration
PNB
Epidural
IRVA
Topical** most common
70
Q

how is Prilocaine supplied

A

1%
2%
3%
4%

71
Q

what is EMLA cream made of

A

prilocaine/lidocaine

72
Q

dose of prilocaine Infiltration

A

0.5-1% 8mg/kg

73
Q

dose of prilocaine PNB

A

1.5-2% 8mg/kg

74
Q

dose of prilocaine Epidural

A

2-3% 8mg/kg

75
Q

dose of prilocaine IRVA

A

0.25-0.5%

76
Q

what is unique about prilocaine?

A

it dose not ventilate
like mepivacaine
DO NOT GIVE EPI WITH

77
Q
Max dose of prilocaine for all routes:
Infiltration
PNB
Epidural
IRVA
A

600mg

78
Q

% binding of prilocaine and what does that mean

A

55%

intermediate duration

79
Q

metabolism of prilocaine

A

Most rapid metabolism of all amide Las

Metabolism it forms orthotoluidine

→ methmoglobinemia

hepatic BUT ALSO RENAL* only amide

80
Q

onset of prilocaine and why

A

FAST with all routes

81
Q
Duration of lidocaine and why
Infiltration
PNB
Epidural
IRVA
A
Intermediate b/c 55% protein bound
Infiltration: 1-2 hr
PNB: 1.5-3 hr
Epi: 1-3 hr
IVRA: 0.5-1hr
82
Q

what is the biggest RXN risk with prilocaine

A

LEAST risk of LA toxicity with this one!!

Useful for IVRA
But.. then the risk of methmoglobinemia - limits its use

83
Q

treatment of methmoglobinemia

A

Methylene blue 1-2 mg/kg IV over 5 min max 8mg/kg

84
Q

Adverse effects of prilocaine

A

Methmaglobinemia

Brady, CV arrest, depression, shock, edema, hpotension

CNS: confusion, seizure, drowsiness, LOC, oral parethssia, blurred vsion, tinnitus, RD

85
Q

contraindications of prilocaine

A

Pregnancy Cat B

Minimal vasodilation- GOOD if you can not add epi to lidocaine

86
Q

Etidocaine trade name

A

Duranest

87
Q

clinical uses of etidocaine

A

Infiltration
PNB
Epidural

88
Q

how is etidocaine supplied?

A

0.5%
1%
1.5%

89
Q

Dose of Etidocaine Infiltration

A

0.5% max 300 mg

90
Q

dose of Etidocaine PNB

A

0.5-1% max 300mg

91
Q

dose of Etidocaine Epidural

A

1-1.5% max 300 mg

92
Q

Max of etidocaine with all routes WITH EPINEPHRINE

A

400mg

93
Q

protein binding of etidocaine and what does that mean

A

94%

long duratoin

94
Q

1/2 life

A

156 minutes

95
Q

metabolism of etidocaine

A

AMIDE

HEPATIC

96
Q

excretion of etidocaine

A
97
Q

onset of etidocaine and WHY

A

SLOW

98
Q

duration of etidocaine and WHY

A

240-480 minutes
4-8 hours
because highly protein bound

99
Q

Clinical uses of cocaine

A

topical anesthesia

vasoconstriction of mucous membrane

100
Q

how is cocaine supplied

A

4%

10%

101
Q

dose of cocaine

A

topical- max 3 mg/kg
200 mg TOTAL
use 4% or 10% solution to anesthetize area being used

102
Q

1/2 life of cocaine

A

75 minutes

103
Q

metabolism of cocaine

A

Hepatic
Plasma cholinesterases
Major metabolies ecgoninemthyl ester and benzoyl ecgonine

104
Q

peak of cocaine

A

Peak 15-40 minutes nasal

105
Q

onset of cocaine

A

FAST

1 min

106
Q

duration of cocaine

A

Topical: > 30 min

Dose dependent

107
Q

adverse reactions with cocaine

A

CV- intense vasoconstriction at ALL doses
HTN, tachy, dysrhythmias, CA vasospasm, MI, ischemia, VF, increased MVO2

CNS: seizures, CVA , chronic abuse causes dopamine depletion

The block of pre-synaptic reuptake of NE and Dop cause the ‘Hgih

108
Q

contraindications of cocaine

A

Pregnancy gat C enters breast milk- congenital malformations, breast milk- irritabile

MI

NO with MAOIs of CAD pts

expensive

109
Q

trade name of chloroprocaine

A

nesacaine

nesacaine-MPF (methylparaben-free)

110
Q

clinical uses of of chloroprocaine

A

Infiltration
PNB
Epidural
Spinal

111
Q

how is chlorocaine supplied?

A

nesacaine 1% or 2%

generic 2% or 3%

112
Q

dose of chloroprocaine Infiltration

A

1%

10 mg/kg

113
Q

PNBdose of chloroprocaine

A

2 %

10mg/kg

114
Q

Epidural dose of chloroprocaine

A

2-3 %

10mg/kg

115
Q

Spinal dose of chloroprocaine

A

2-3% **

PRESERVATIVE FREE

116
Q

max dose of chloroprocaine with Infiltration, PNB, Epidural without epinephrine

A

800 mg

same for all 3

117
Q

max dose of chloroprocaine with spinal

A

1000 mg

* never add epi spinal

118
Q

max dose of chloroprocaine with Infiltration, PNB, Epidural WITH epinephrine

A

1000 mg

119
Q

% protein bound of chloroprocaine and what does that mean?

A

95%

long lasting

120
Q

1/2 life of chloroprocaine

A

0.1 hr

121
Q

onset of chloroprocaine

A

RAPID… WHY!?
because HIGH concentrations 3%!!
even though pKa is 9.1 gradient allows it to be more to rapidly act

122
Q

duration for chloroprocaine

A

0.5-1 %

all routes

123
Q

what is most unique about chloroprocaine?

A

SAFEST OF ALL LOCALS!
least CNS
CV toxicity of all LAs

124
Q

adverse reactions of chloroprocaine

A

Brady, arrest, hypotension, VF

CNS tox- seizures- very rare, dizziness, anxiety, restlessness, tinnitus, LOS, blurred vision

Edema, erythema, pruritus, urticarial

Chondrolysis

RD

Allergy

125
Q

contraindications of chloroprocaine

A

Pregnancy category C

Immune anti-inflammatory

PRESERVATIVE FREE PREPARATIONS FOR NEUROAXIAL BLOCK

126
Q

Tetracaine trade names

A
Ametop
Pontocaine
Tetcaine
Altacaine
TetraVisc
127
Q

Clinical uses of tetracaine

A

Topical- optho

Spinal

128
Q

dose of tetracaine topical and %

A

2% topical

0.2mg/kg

129
Q

dose of tetracaine spinal

A

use 0.5%- mg/kg?

130
Q

max dose of tetracaine

A

same for both

20mg

131
Q

protein binding of tetracaine and what does that mean

A

76%

intermediate duration

132
Q

metabolism of tetracaine

A

Hydrolysis by PLASMA CHOLINESTERASE
All amides

Slower than procaine

To aminobenzoic acid

133
Q

onset of tetracaine

A

fast 5 min both routes

134
Q

duration of topical tetracaine

A

0.5-1 hr

135
Q

duration of spinal tetracaine

A

2-6 hours

136
Q

contraindications with esters

A

Hypersenvsitive to ESTER LA

Caution w/decreased plasma cholinesterase levels- Dibucain #

137
Q

Adverse Reactions tetracaine

A

CV: arrest, hypotension

PULM: arrest, bronchospasm, dyspnea

CNS: seizure, disy, drowsy, LOC tinnitus, blurred vision, miosis

GI: N/V

Heme/Onc: Methmoglobinemia

Itching/anaphylaxis

138
Q

what about tetracaine and PNB and IVRA

A

limited d/t toxicity with larger doses

139
Q

trade name of procaine

A

procaine

140
Q

spinal dose of procaine

A

10%

15 mg/kg

141
Q

max spinal dose of procaine

A

1000 mg

142
Q

how is procaine supplied

A

10% for spinals

143
Q

what is procaine NOT recommended for

A

topical, Epidural, PNB, IVRA

144
Q

protein binding of procaine

A

6%

rapid off NOT long duration

145
Q

duration spinal procaine

A

0.5-1 hr

146
Q

onset of procaine

A

slow

147
Q

metabolism of procaine

A

Hydrolysis by cholinesterase primarily in the plasma and to a lesser extent in the liver

Intermediate RATE

Hydrolyzed to PABA (paraaminobenzoic acid)

148
Q

run with procaine

A

Allergy to PABA (paraaminobenzoic acid)

149
Q

Intralipid brand name

A

Intralipid

Liposyn

150
Q

how is intralipid supplied

A

20%
100mL most common
250, 500, 1000 mL

151
Q

MOA intralipid

A

1) exogenous lipids provide an alternative source of binding of local anesthetics- LIPID SINK- High lipid partition coeff and large Vd- bupivacaine, L-bupicacaine, Ropivacaine

2) Reversal of mitochondrial fatty acid transport inhibition
LA inhibit an enzyme used in mitochondrial fatty acit metabolism and transpot- b/c fatty acids are involved in 80-90% of ATP synthesis leading to CV toxicity. Lipid infusion increase the intracellularfatty acid content enough to overcome the inhibition of these enzymes by LA

152
Q

dosing of intralipid

A

Bolus: 1.5 mg/kg q5min x3

70kg- 100mL

100 kg pt-150 mL

Infusion
0.25 mL/kg/min
70 kg- 1000mL/hr

100kg – 1500mL/hr

2nd Infusion:
0.5 mL/kg/hr

70kg- 2000mL/hr

100kg
3000mL/hr

153
Q

1/2 life of intralipid

A

0.5-1 hr

154
Q

metabolism of intralipid

A

Fatty acids, phospholipids and glycerol are metabolized by cells to ATP, CO2 and water

155
Q

excretion of intralipid

A

Biliary excretion of phospholipids

156
Q

adverse rxn

A

CV instability

Pancreatitis

Hypoproteinemia

Septicemia, fever, Allergic xn

Neuro symptoms of LA tox BUT

CV collapse may be the first symptom

157
Q

composition of intralipid

A

100mL most common
20% = 20g Soybean Oil, 1.2g Lecithin
2.2g glycerol
NaOH & 100mL

158
Q

contraindications with intralipid

A

Do not give with severe EGG allegy