More Block 2 Flashcards
BZD MOA?
Activates GABAa receptors
Increases Cl influx
No analgesic affect
Diazepam
Lorazepam
Midazolam
Which one has the shortest and longest t1/2?
Midazolam = shortest (2hrs)
Diazepam = longest (up to 55hrs)
BZD AE (especially w/ opioids)?
Respiratory depression
Propofol MOA?
Activates GABAa receptors
Increases Cl influx
No analgesic affect, but induces anesthesia + an antiemetic
Propofol formulation info?
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
Propofol PK info?
Zero oral bioavailability
Elimination is unchanged if you have liver/kidney damage
Propofol AE?
Respiratory depression (needs monitoring!)
Hypotension (dose-dependent vasodilation)
Bradycardia, reduction in heart contractility
Propofol Infusion Syndrome (PRIS) – rare but potentially fatal
Fospropofol metabolism?
Metabolized by alkaline phosphatase
Fospropofol formulation and AE?
Minimal injection site pain and hyperlipidemia
Water Soluble
Less frequent of respiratory depression or hypotension
Ketamine MOA?
NMDA antagonist
Ketamine use?
For analgesia (supposedly no respiratory depression)
Hallucinations + Date rape drug
Ketamine PK?
Typically given as IV, IM is too painful
Ketamine AE?
Emergence reactions
Transient increase in BP, HR, CO
Precedex MOA?
Alpha 2 agonist
Locus coeruleus – activates sleep pathways
Spinal cord – analgesia
Precedex AE?
Hypotension/hypertension
Bradycardia
Does NOT cause respiratory depression
How is skeletal muscle initiated?
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
General paralytic MOA?
Blocks ACh from binding to ACh nicotinic receptor
What is the only depolarizing paralytic?
Succinylcholine
Everything else is competitive/non-depolarizing (roc, vec, nimbex)
Competitive/non-depolarizing paralytic MOA?
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
How does paralysis occur based on susceptibility?
First: face, eye
Then: fingers, limbs, neck, trunk
Last: Intercostal muscle, diaphragm
PK info on competitive/non-depolarizing paralytics?
Zero oral bioavailability + cant cross BBB
Roc
Vec
Pancuronium
Nimbex
Metabolism info?
Roc + Vec = deacetylated in liver, no excreted into bile unchanged
Pancuronium = excreted unchanged in urine
Nimbex = degraded by plasma and ester hydrolysis
Succinylcholine MOA?
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
Succinylcholine AE?
Soreness, hyperthermia, hyperkalemia, apnea
What does the BPS pain scale look at? CPOT
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
Fentanyl
Hydromorphone
Morphine
If you have liver issues, what are the better options?
Hydromorphone + Morphine
Treatment options for neuropathic pain?
Gabapentin
Carbamazepine
Pregabalin
What are some misc. treatment options that are never recommended for pain + ICU?
Lidocaine
> 1 dose NSAID
What does the RASS score tell you?
Ranges from -4 to +5
Negative = sedated
Positive = agitated
Diazepam
Lorazepam
Midazolam
If you have liver issues, which one should you choose?
Lorazepam
Diazepam
Lorazepam
Midazolam
Which one is associated with propylene glycol toxicity?
Lorazepam
What did the Awake and Breathing Controlled trial show us?
Taking ppl off sedation and having them breathe on their own and placing them back on 1/2 dose sedation improve ICU stay
What is the CAM-ICU assessment used for?
Delirium
Looks at:
Mental status change
Inattention
Altered consciousness or disorganized thinking
ICDSC is also used
How do you treat delirium?
Prevention is #1
Haldol might work
Quetiapine might work too
Use both in short term
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?
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
Roc
Vec
Pancuronium
Nimbex
Which one is associated with increased risk of tachycardia?
Pancuronium
Roc
Vec
Pancuronium
Nimbex
Which one is associated with increased risk of hypotension?
None; its atracurium
ICU acquired muscle weakness is typically associated with both paralytics and ______
steroids
Which paralytic should be used for these conditions?
Acute respiratory distress syndrome (ARDS)\
Status asthmaticus
Targeted temperature management
Elevated intracranial pressure
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
Succinylcholine Roc Vecuronium Pancuronium Nimbex
Which one doesnt involve in renal/liver issues when eliminating rx?
Succ + Nimbex (#1)
Succ via pseudocholinesterase hydrolysis
Nimbex via Hoffman elimination and ester hydrolysis
If pt requires a paralytic and nimbex is out, what are the next few drugs you could use?
Next up is roc, then vec, then lastly pancuronium
What are some medications that can enhance the blockade of paralytics?
Abx
CV drugs
Steroids
Anesthetics
Which conditions can enhance the blockade of paralytics?
Low calcium, sodium, potassium
High magnesium
Acidosis
What are some medications that can decrease the blockade of paralytics?
Anticonvulsants
Methylxanthine
Ranitidine
Which conditions can decrease the blockade of paralytics?
High calcium
Alkalosis
Nimbex bolus + continuous dosing?
Bolus = 0.1-0.2mg/kg
Continuous = 3mcg/kg/min initially, then 1-2mcg/kg/min
Before giving a dose of paralytics, what should you give the patients first?
Sedation + analgesia
How do you monitor for the effects of NMDAs?
- Clinical assessment
2. Peripheral nerve stimulation (TOF)
What is the Train-of-four assessment?
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
How do you reverse paralytics?
For NON-DEPOLARIZING agents only:
Neostigmine
Pyridostigmine
Bridion**
**Roc or Vec only
Whats typically given with neostigmine/pyridostigmine due to excess levels of ACh?
To prevent muscarinic effects, give glycopyrrolate or atropine
Bridion doesnt have these muscarinic effects
Succinylcholine AE?
Bradycardia
Succinylcholine dosing considerations
Increase dose in myasthenia gravis
Dont give w/ h/o of malignant hyperthermia
Avoid in children
Raises potassium by 0.5
What do you use to treat malignant hyperthermia?
Dantrolene; reduces calcium release
Etomidate
Ketamine
Propofol
BZD
Which one can you give in septic shock?
Ketamine + BZD
Etomidate
Ketamine
Propofol
BZD
Which one can you give in status asthmaticus?
Ketamine + Propofol
Etomidate
Ketamine
Propofol
BZD
Which one should someone w/ soy allergy avoid?
Propofol
Etomidate
Ketamine
Propofol
BZD
Which one causes decreased BP and bradycardia?
Propofol
Etomidate
Ketamine
Propofol
BZD
Which one should be avoided in TBI or MI?
Ketamine
Etomidate
Ketamine
Propofol
BZD
Which one causes a potential of transient adrenal suppression for 48hrs?
Etomidate
Etomidate
Ketamine
Propofol
BZD
Which one can you give in seizures?
BZD
Etomidate
Ketamine
Propofol
BZD
Which one should NOT be used in septic shock?
Etomidate + Propofol
Etomidate
Ketamine
Propofol
BZD
Which one should NOT be used in bradycardia?
Propofol
What are the pretreatment options for patients before paralytics?
LOAD, M
Lidocaine; suppresses cough, sodium channel, an amide (allergy), metabolized by liver
Opioids
Atropine; potentially used for pediatrics
Defasciculating paralytic
Low dose midazolam
