MAGA- Exam 2 Flashcards
Multimodal anesthesia for GA
What enzyme catalyzes the synthesis of prostaglandins?
COX (Cyclooxygenase)
This form of COX is responsible for gastric protection, hemostasis, and renal function…
COX-1
COX-1 or COX-2?
Ubiquitous, “physiologic”, inhibition is responsible for many adverse effects
COX-1
COX-1 or COX-2?
Pathophysiologic, expressed at sites of injury, not protective
COX-2
COX-2 is responsible for which symptoms?
Pain, inflammation, and fever
What are the three main properties of NSAID drugs?
Analgesic
Anti-inflammatory
Antipyretic
Slide 34
What are types of non specific NSAIDS
ibuprofen, naproxen, aspirin, tylenol
Increased gastric irritation with these drugs
Slide 34
Multimodal includes _____ acting anesthetics agents and _______ 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
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 inhibitors have what effects compared to non specific
Comparable analgesia
It may be associated with lower GI effects
possible increased risk in MI and CVA
dosage ceiling causes incresased side effects
Slide 35
What was the first COX-2 inhibitor that decreases PG synthesis?
Celecoxib (Celebrex)
Slide 36
What is the dosage for Celebrex?
When does it reach its peak?
200 to 400 mg PO QD
peak- 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
What are the side effects of Ondansetron?
HA, Constipation and some QT prolongation!
What is the duration & dose of Ondansetron?
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?!
Corticosteroids increase the effectiveness for which meds?
MOA is unknown: It works on glucocorticoid receptors in Nucleus Tractus Solitarius (NTS)!
Corticosteroids increase effectiveness for 5 HT3 antagonists and droperidol!
What is the dose for Dexamethasone (Decadron)?!
What is the MOA of Dexamethasone (Decadron)?
4-10 mg
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!
No adverse effects of single dose- diabetics will be fine
-Causes perineal itching and burning if given fast
(Slide 53)
According to the TXWES medication guide, what are the doses for Acetaminophen (Ofirmev), Ketorlac (Toradol), & Ibuprofen (Caldor).
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; used as a short acting anesthetic agent
Slide 42
Ketamine inhibits _____ activation.
NMDA
(We do not need to know TEAMHealth Formula in this slide)
What is the induction dose of Ketamine?
0.5-1.5 mg/kg/IV
4-8 mg/kg IM
Slide 43
What is the maintenance dose of Ketamine?
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
Careful monitoring with lidocaine?
cardiac, hepatic and renal function!
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/ 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)
For Ofirmev, what is the Dose, Peak effect time, and duration?
Dose 1000 mg IV Q4-6H
max 3000-4000 mg QD
Peak for PO: 1-3 hr
IV Peak: 30 min to 1 hr
Duration: 6-8 hours
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 Keorolac, what is the MOA, Peak effect time, and Dose
MOA: Inhibits PG synthesis by inhibiting COX 1 and COX 2
Peak: 45 to 60 minutes IV
Dose: 15 to 30mg q6h (1/2 dose in elderly)
Max Dose: 60-120mg QD
Has no effect on biliary tract, and no ventilatory/ cardiac depression :)
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 mcg/mL = analgesia
5-10 = circum-oral numbness; tinnitus; skeletal muscle twitching; systemic HYPOtension; myocardial depression
(slide 46)
Lidocaine plasma concentration of ____ causes what?
10-15 mcg/ml = ?
15-25 mcg/ml = ?
These are OD levels
10-15 = Sz’s; unconsciousness
15-25 = apnea (2/2 affecting the pons and medulla oblongata); coma
(slide 46)
Lidocaine plasma concentration of ____ causes what?
> 25 mcg/ml
Cardiovascular depression!!!! (need 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)
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)
What receptor does magnesium block
It is an NMDA antagonist (N-methyl-D-asparte)
-It probably potentiatates opiods centrally and peripherally
(slide 48)
Mg++ regulates what?
(HINT: 4)
- Ca++ access into the cell and actions within cell
- Neurotransmission
- Cell signaling
- Enzyme function
(slide 48)
Mg++ has _______ passage across the ___
2 contraindications for renal faulure
limited passage across brain blood barrier
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)
What opioid requirement does the use of Mg++ significantly decrease?
Fentanyl
(slide 49)
Ibuprofen:
MOA
Contraindications
Dose
Peak
Excretion
-MOA: anti-inflammation, analgesia antipyretic, inhibits COX 1 and 2
-C/I to allergies, CABG, bleeding ulcers
Dose: 200- 800 IV over 30 min Q6H
Max: 3200 mg/day
Peak: 1-2 hours
Excretion: urine and bile
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?
Proposal, 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 Voltage-Gated Ca channels, inhibits release of glutamate at the dorsal horn 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)
Mu 1 effects and agonists
analgesia, euphoria, low abuse potential and miosis, bradycardia, hypothermia, retention
Agonists are endorphins, moprhine, syntehtic opioids
Mu2 effects and agents
analgesia, depression of ventilation, physical dependence and constipation
Agonists- endorphine, synthetic opioids and morphine
kappa effects and agonists
analgesia, dysphoria, sedation, low abuse potential, myosis, diuresis
Delta effects and agonists
analgesia, ventilation depression, physical dependence and urinary retention
enkephalins
Antagonists for all opioid receptors
naloxone, naltrexone, nalmefene
Gabapentin side effects
somnolence, fatigue, ataxia, vertigo, GI disturbances, abrupt withdrawal in seizure patients, weight gain
Effects of NSAIDS
-decrease activation of peripheral nociceptors
-No addictive potential
-Preemtive analgesia
-less N/V
-Long duration of action
Abscense of cognitive effects
Ketorolac analgesic properties
Only a moderate anti-inflammatory
May potentiate opioid antinocipception
