*MAGA (Exam II) Flashcards
What are the components of today’s Multimodal practice?
- Preoperative Fluid
- Carbohydrate Loading
- Short Acting Anesthetic Agents
- Opioid Sparing
- Temperature Management
- Cerebral/neuromuscular
S2
What are Nonopioid Alternatives for the treatment of pain?
This is a list
- PT & OT
- Massage Therapy
- Acupuncture
- Chiropractic Care
- Osteopathic Manipulative Treatment (OMT)
- Behavioral Interventions
- Topical Treatments and Medications
- Cold & Heat
- Exercise
- Weight Loss
- Diet and Nutrition
- Yoga & Tai Chi
- TENS
- OTC Medications
- Interventional Pain Management
- Nonopioid Anesthesia
S11
What refers to the anesthetic technique of using medications to provide anesthesia and post-operative pain relief in a way that does not require opioids?
Nonopioid Anesthesia
S11
What is the pain response pathway? (5)
(this was in the pain pathway slide set too)
S17
What is the MOA of Gabapentin?
GABA analogue
(not act like GABA)
Binds voltage gated Ca++ channels:
enhances descending inhibition
inhibits excitatory neurotransmitter release
S25*
Is Gabapentin lipid soluble?
What percentage protein-binding occurs?
What’s it’s E 1/2 time?
- Yes, Lipid soluble
- 0% protein-bound
- Brief E 1/2 time – need redosing required
S25
Does Gabapentin have any drug-drug interactions?
No drug interactions
S25
What are indicated uses for gabapentin?
- Seizures
- Neuropathic pain
- Chronic pain syndromes.
S26
Regarding Gabapentin’s preemptive analgesia, What 3 studies/ procedures is it used in?
- Spine surgeries
- Orthopedic procedures
- Major abdominal procedures.
S27
What is the PO dose of preemptive Gabapentin?
When should we give it?
300-1200mg PO
1-2 hrs prior to OR
start slow then build up
S27
For Preemptive Gabapentin, what patient population is it contraindicated for?
- MG and Myoclonus patients
- Reduce dose in elderly patients
S27
What are Gabapentin’s side effects?
Think ↑GABA effects
- Somnolence
- fatigue
- ataxia
- vertigo
- GI disturbances: constipation
- abrupt withdrawal in seizure pts (when Gaba is used as an antiepiliptic) –> causing seizures
- wt gain
S29
Evidenced based slide
What evidence based conclusion was found with the study “Efficacy of preoperative gabapentin in spinal surgery: a meta-analysis of randomized controlled trials”
despite of 10 RCTs and low sample size, Gabapentin is:
* effective in reducing post operative opioid consumption
* it also lessen the side effects after spinal surgery
* lower dose should be given to elderly
S30
What are the effects of NSAIDs?
- Decrease activation of peripheral nociceptors
- No addictive potential
- Preemptive analgesia
- Absence of ventilatory depression
- Less nausea and vomiting
- Absence of cognitive effects
- Long duration of action
S32
What enzyme catalyzes the synthesis of prostaglandins?
COX (Cyclooxygenase)
S33
This form of COX is responsible for gastric protection, hemostasis, and renal function…
COX-1
S33
COX-1 or COX-2?
Ubiquitous, “physiologic”, inhibition of this enzyme is responsible for many adverse effects.
COX-1
S33
COX-1 or COX-2?
Pathophysiologic, expressed at sites of injury, not protective.
COX-2
S33
COX-2 propagation is responsible for which symptoms?
Pain, inflammation, and fever
S33
What are the three main properties of NSAID drugs?
Analgesic
Anti-inflammatory
Antipyretic
S34
Are the following drugs non-specific or COX-2 selective?
–Ibuprofen, naproxen, aspirin, and ketorolac–
What gastric symptomology would be seen with administration of these drugs?
Non-Specific
Increased gastric irritation with these drugs
S34
Celecoxib (Celebrex), Rofecoxib (Vioxx), Valdecoxib (Extra), Parecoxib (Dynastat) are all examples of what?
COX-2 Selective NSAIDs
S34
Do COX-2 selective NSAIDs effect platelets?
No
S35
Because COX-2 selective NSAIDs have no effect on platelets, this would increase the chance of what pathology?
Clotting (think MI and CVA)
S35
COX-2 selective and nonspecific inhibitors have _____________ analgesia
Comparable
S35
What was the first COX-2 inhibitor that decreases PG synthesis?
Celecoxib (Celebrex)
S36
What is the dosage for Celebrex?
200 to 400 mg PO QD
S36
Celebrex reaches its peak in…
3 hours
S36
What is the MOA for Ofirmev?
- Reduces prostaglandin metabolites
- No significant anti-inflammatory property
- Analgesic/antipyretic
S38
What is the contraindication of Ofirmev?
Hepatic Dysfunction
S38
What is the dose and max dose of Ofirmev?
1000 mg IV Q4-6H
max 3000-4000 mg QD
*make sure to report administration to PACU!
S38
What is the peak of Ofirmev in PO and IV?
PO: 1-3 hours
IV: 30 mins to 1 hour
S38
What is the duration of Ofirmev?
6 - 8 hours
S38
What is the MOA of Ketorolac?
Inhibits PG synthesis by inhibiting COX 1 and COX 2
Potent analgesic property
Only moderate anti-inflammatory
May potentiate opioid antinociception
S40
What are some contraindications to consider when giving Toradol?
- Severe Renal impairment
- Risk for bleeding – low platelet count
- CAD
- CABG
- Pregnant
- NSAID allergy
- Allergy to Tylenol
S40
What is the peak of Ketorolac?
45 to 60 minutes IV
S40
What is the dose and max dose of Ketorolac?
Dose: 15 to 30mg q6h (1/2 dose in elderly)
Max Dose: 60-120mg QD
S40
Ketorolac has no effects on what?
- biliary tract
- ventilatory/cardiac depression
S40
What is the MOA of Ibuprofen?
- anti-inflammatory
- analgesic
- antipyretic
- inhibits COX 1 and 2
S41
What is the contraindication for Ibuprofen?
- Allergies to NSAIDs
- CABG
- bleeding ulcers, etc
S41
What is the dose and max dose of Ibuprofen?
200 to 800 IV over 30 mins Q6H PRN
max: 3200 mg/day
S41
What is the peak of Ibuprofen?
1 - 2 hours
S41
Where is Ibuprofen excreted?
Urine and Bile
S41
What short acting anesthestic agents are used for multimodal practice?
- Propofol (Diprivan)
- Ketamine
S42
What are the doses for Lidocaine?
What to monitor for?
Initial bolus = 1 to 2 mg/kg IV over 2 - 4 min
Drip = 1 to 2 mg/kg/hour
terminated at 12-72 hours
monitor: cardiac, hepatic, & renal dysfunction
S44
Lidocaine plasma concentration of ____ causes what?
1-5 mcg/ml = ?
5-10 mcg/ml = ?
1-5 = analgesia
5-10 = circum-oral numbness; tinnitus; skeletal muscle twitching; systemic HYPOtension; myocardial depression
S45
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 (pons & medullary depression); coma
S45
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!!!
CLASS question
This med has anti-nociceptive effects by antagonizing the NMDA receptor and “probably” potentiates opioids centrally and peripherally.
Magnesium
S47
Mg++ regulates which four cellular functions?
- Ca++ access intracellularly.
- Neurotransmission
- Cell signaling
- Enzyme function
S47
Which ion has limited movement across the BBB?
Mg⁺⁺
S47
What conditions are contraindicative for magnesium administration?
Myasthenia Gravis & Renal Failure
S47
What is Mg⁺⁺ dosing for the following two situations?
Preop:
Intraop:
- Preop: 50 mg/kg IV
- Intraop: 8 mg/kg/hr IV
S48
Which patients receive magnesium sulfate most often per Castillo?
Preeclamptic & eclamptic OB patients.
Slide 46
What opioid requirement does the use of Mg++ significantly decrease?
Fentanyl
S48
What adverse side effects could occur with Mg++?
- Hypotension
- bradycardia
* ataxia
* somnolence
* decreased muscular tone – check DTR
S48
Evidence-based slide
What evidence based conclusion was found with the study “Perioperative systemic magnesium to minimize postoperative pain”?
a lot of these procedures used Fentanyl, Morphine PCA, Toradol, Tramadol and Meperadine as part of their pain pathway (not specific multimodal)
they did test for early and late pain at rest and movement
further findings: there is significant pain relief or pain control or reduction at intraop and post-op vs intraop only
also cited in their findings that there are opioid side effects of dizziness headache and post op nausea and vomiting
S49
What is the MOA of Ondansetron and the use?
- First 5-HT3 antagonist
- Approved for CINV
S50
Ondansetron is equivocal to what two drugs in its treatment of N/V?
Droperidol & Metoclopramide
What are the side effects of Ondansetron?
S50
- HA
- Constipation
- some QT prolongation
S50
What is the dose of Ondansetron?
4 mg IV (up to 8 mgs)
Pediatrics: 0.1 mg/kg IV
S50
What is the duration of Ondansetron?
plasma half life is 4 hours!
S50
What is the MOA of Corticosteroids in the treatment of N/V?
MOA is unknown
It works on glucocorticoid receptors in Nucleus Tractus Solitarius (NTS).
S51
Why are Corticosteroids used with 5-HT3 (Ondansetron) & Droperidol?
Increase effectiveness for 5 HT3 antagonists and Droperidol
S51
What is the dose for Dexamethasone (Decadron)?
8 - 10 mg IV
S52
What is the MOA of Dexamethasone (Decadron)?
- Anti-inflammatory
- inhibition of phospholipase and cytokines and stabilization of cellular membrane.
S52
What is the delay of onset of Dexamethasone (Decadron)?
2 hours
S52
What is the efficacy of Dexamethasone (Decadron)?
24 hours
S52
Are there any adverse effects of a single dose of Dexamethasone (Decadron)?
What occurs if it is pushed fast?
- Nope
- Perineal burning/itching
S52
According to the TXWES medication guide, what are the doses for Acetaminophen (Ofirmev), Ketorlac (Toradol), & Ibuprofen (Caldor).
Slide 60
