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IPT: CC > More Block 2 > Flashcards

More Block 2 Flashcards

1
Q

BZD MOA?

A

Activates GABAa receptors

Increases Cl influx

No analgesic affect

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2
Q

Diazepam
Lorazepam
Midazolam

Which one has the shortest and longest t1/2?

A

Midazolam = shortest (2hrs)

Diazepam = longest (up to 55hrs)

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3
Q

BZD AE (especially w/ opioids)?

A

Respiratory depression

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4
Q

Propofol MOA?

A

Activates GABAa receptors

Increases Cl influx

No analgesic affect, but induces anesthesia + an antiemetic

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5
Q

Propofol formulation info?

A

Not an antimicrobial preserved product (must have strict aseptic technique when handling)

Reported to have injection site pain and hyperlipidemia

Stored at 4-25C, no freezing

Water INsoluble

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6
Q

Propofol PK info?

A

Zero oral bioavailability

Elimination is unchanged if you have liver/kidney damage

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7
Q

Propofol AE?

A

Respiratory depression (needs monitoring!)

Hypotension (dose-dependent vasodilation)

Bradycardia, reduction in heart contractility

Propofol Infusion Syndrome (PRIS) – rare but potentially fatal

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8
Q

Fospropofol metabolism?

A

Metabolized by alkaline phosphatase

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9
Q

Fospropofol formulation and AE?

A

Minimal injection site pain and hyperlipidemia

Water Soluble

Less frequent of respiratory depression or hypotension

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10
Q

Ketamine MOA?

A

NMDA antagonist

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11
Q

Ketamine use?

A

For analgesia (supposedly no respiratory depression)

Hallucinations + Date rape drug

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12
Q

Ketamine PK?

A

Typically given as IV, IM is too painful

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13
Q

Ketamine AE?

A

Emergence reactions

Transient increase in BP, HR, CO

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14
Q

Precedex MOA?

A

Alpha 2 agonist

Locus coeruleus – activates sleep pathways

Spinal cord – analgesia

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15
Q

Precedex AE?

A

Hypotension/hypertension

Bradycardia

Does NOT cause respiratory depression

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16
Q

How is skeletal muscle initiated?

A

Action potential causes depolarization of calcium channel

Calcium channel opens and influx of calcium releases ACh

ACh binds to ACh nicotinic receptor

Sodium enters the muscle cell and ACh is degraded by AChE

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17
Q

General paralytic MOA?

A

Blocks ACh from binding to ACh nicotinic receptor

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18
Q

What is the only depolarizing paralytic?

A

Succinylcholine

Everything else is competitive/non-depolarizing (roc, vec, nimbex)

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19
Q

Competitive/non-depolarizing paralytic MOA?

A

Blocks ACh from binding to receptor however the effect can be overcome by excessive ACh like AChE inhibitors unless there is a high dose of this paralytic, then excessive ACh cant overcome it

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20
Q

How does paralysis occur based on susceptibility?

A

First: face, eye
Then: fingers, limbs, neck, trunk
Last: Intercostal muscle, diaphragm

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21
Q

PK info on competitive/non-depolarizing paralytics?

A

Zero oral bioavailability + cant cross BBB

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22
Q

Roc
Vec
Pancuronium
Nimbex

Metabolism info?

A

Roc + Vec = deacetylated in liver, no excreted into bile unchanged

Pancuronium = excreted unchanged in urine

Nimbex = degraded by plasma and ester hydrolysis

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23
Q

Succinylcholine MOA?

A

Drug causes membrane depolarization but AChE cant hydrolyze it and causes fasciculations

After a prolonged time,
Phase I - Depolarizing = flaccid paralysis (can be augmented by AChE inhibitors

Phase II - slowly converts to this phase of non-depolarization

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24
Q

Succinylcholine AE?

A

Soreness, hyperthermia, hyperkalemia, apnea

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25
Q

What does the BPS pain scale look at? CPOT

A

Facial expression

Upper limbs

Ventilation compliance

Scores from 3-12, intervene when score is ≥6

CPOT adds vocalization, muscle tension instead of upper limbs, body movement

CPOT ≥2 is significant

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26
Q

Fentanyl
Hydromorphone
Morphine

If you have liver issues, what are the better options?

A

Hydromorphone + Morphine

27
Q

Treatment options for neuropathic pain?

A

Gabapentin
Carbamazepine
Pregabalin

28
Q

What are some misc. treatment options that are never recommended for pain + ICU?

A

Lidocaine

> 1 dose NSAID

29
Q

What does the RASS score tell you?

A

Ranges from -4 to +5

Negative = sedated

Positive = agitated

30
Q

Diazepam
Lorazepam
Midazolam

If you have liver issues, which one should you choose?

A

Lorazepam

31
Q

Diazepam
Lorazepam
Midazolam

Which one is associated with propylene glycol toxicity?

A

Lorazepam

32
Q

What did the Awake and Breathing Controlled trial show us?

A

Taking ppl off sedation and having them breathe on their own and placing them back on 1/2 dose sedation improve ICU stay

33
Q

What is the CAM-ICU assessment used for?

A

Delirium

Looks at:

Mental status change
Inattention
Altered consciousness or disorganized thinking

ICDSC is also used

34
Q

How do you treat delirium?

A

Prevention is #1

Haldol might work
Quetiapine might work too

Use both in short term

35
Q

Because paralytics dont just target nicotinic receptors, they also target muscarinic receptors which are M1, 2, and 3. What organs are affected and what AE are expected?

A

M1 (Increased IP3) = CNS + parietal cells, CNS excitation + increased gastric acid secretion

M2 (decreased cAMP) = Heart, decreased rate, force, and AV conduction

M3 (Increased IP3) = smooth muscles + exocrine glands; smooth muscle contraction except vasodilation and glandular secretion

36
Q

Roc
Vec
Pancuronium
Nimbex

Which one is associated with increased risk of tachycardia?

A

Pancuronium

37
Q

Roc
Vec
Pancuronium
Nimbex

Which one is associated with increased risk of hypotension?

A

None; its atracurium

38
Q

ICU acquired muscle weakness is typically associated with both paralytics and ______

A

steroids

39
Q

Which paralytic should be used for these conditions?

Acute respiratory distress syndrome (ARDS)\

Status asthmaticus

Targeted temperature management

Elevated intracranial pressure

A

ARDS - Nimbex

Status asthmaticus - none, should be the absolute last thing you should try

Temp management - no recommendation for hypothermia following cardiac arrest, but for therapeutic hypothermia, but you could use any; you want to prevent body from shivering to use less O2

Elevated ICP - can only be used if deep sedation is used and insufficient, same MOA as temp management

40
Q 
Succinylcholine
Roc
Vecuronium
Pancuronium
Nimbex

Which one doesnt involve in renal/liver issues when eliminating rx?

A

Succ + Nimbex (#1)

Succ via pseudocholinesterase hydrolysis

Nimbex via Hoffman elimination and ester hydrolysis

41
Q

If pt requires a paralytic and nimbex is out, what are the next few drugs you could use?

A

Next up is roc, then vec, then lastly pancuronium

42
Q

What are some medications that can enhance the blockade of paralytics?

A

Abx

CV drugs

Steroids

Anesthetics

43
Q

Which conditions can enhance the blockade of paralytics?

A

Low calcium, sodium, potassium

High magnesium

Acidosis

44
Q

What are some medications that can decrease the blockade of paralytics?

A

Anticonvulsants

Methylxanthine

Ranitidine

45
Q

Which conditions can decrease the blockade of paralytics?

A

High calcium

Alkalosis

46
Q

Nimbex bolus + continuous dosing?

A

Bolus = 0.1-0.2mg/kg

Continuous = 3mcg/kg/min initially, then 1-2mcg/kg/min

47
Q

Before giving a dose of paralytics, what should you give the patients first?

A

Sedation + analgesia

48
Q

How do you monitor for the effects of NMDAs?

A
  1. Clinical assessment

2. Peripheral nerve stimulation (TOF)

49
Q

What is the Train-of-four assessment?

A

4 pulses to deplete ACh

Goal = 1-2 out of 4 twitches

T4/T1; if its ≥0.9 it means they can breath on their own and are probably not paralyzed

But dont rely on this assessment alone, use synchrony and oxygen consumption to guide therapy

50
Q

How do you reverse paralytics?

A

For NON-DEPOLARIZING agents only:

Neostigmine

Pyridostigmine

Bridion**

**Roc or Vec only

51
Q

Whats typically given with neostigmine/pyridostigmine due to excess levels of ACh?

A

To prevent muscarinic effects, give glycopyrrolate or atropine

Bridion doesnt have these muscarinic effects

52
Q

Succinylcholine AE?

A

Bradycardia

53
Q

Succinylcholine dosing considerations

A

Increase dose in myasthenia gravis

Dont give w/ h/o of malignant hyperthermia

Avoid in children

Raises potassium by 0.5

54
Q

What do you use to treat malignant hyperthermia?

A

Dantrolene; reduces calcium release

55
Q

Etomidate
Ketamine
Propofol
BZD

Which one can you give in septic shock?

A

Ketamine + BZD

56
Q

Etomidate
Ketamine
Propofol
BZD

Which one can you give in status asthmaticus?

A

Ketamine + Propofol

57
Q

Etomidate
Ketamine
Propofol
BZD

Which one should someone w/ soy allergy avoid?

A

Propofol

58
Q

Etomidate
Ketamine
Propofol
BZD

Which one causes decreased BP and bradycardia?

A

Propofol

59
Q

Etomidate
Ketamine
Propofol
BZD

Which one should be avoided in TBI or MI?

A

Ketamine

60
Q

Etomidate
Ketamine
Propofol
BZD

Which one causes a potential of transient adrenal suppression for 48hrs?

A

Etomidate

61
Q

Etomidate
Ketamine
Propofol
BZD

Which one can you give in seizures?

A

BZD

62
Q

Etomidate
Ketamine
Propofol
BZD

Which one should NOT be used in septic shock?

A

Etomidate + Propofol

63
Q

Etomidate
Ketamine
Propofol
BZD

Which one should NOT be used in bradycardia?

A

Propofol

64
Q

What are the pretreatment options for patients before paralytics?

A

LOAD, M

Lidocaine; suppresses cough, sodium channel, an amide (allergy), metabolized by liver

Opioids

Atropine; potentially used for pediatrics

Defasciculating paralytic

Low dose midazolam

IPT: CC (7 decks)

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