Multimodal (Exam 2) Flashcards by B B

Multimodal anesthesia for general anesthesia includes these two aspects.

Short-acting Anesthetic agents
Opioid sparing

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What enzyme catalyzes the synthesis of prostaglandins?

COX (Cyclooxygenase)

Slide 33

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This form of COX is responsible for gastric protection, hemostasis, and renal function…

COX-1

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COX-1 or COX-2?

Ubiquitous, “physiologic”, inhibition of this enzyme is responsible for many adverse effects.

COX-1

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COX-1 or COX-2?

Pathophysiologic, expressed at sites of injury, not protective.

COX-2

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COX-2 propagation is responsible for which symptoms?

Pain, inflammation, and fever

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What are the three main properties of NSAID drugs?

Analgesic
Anti-inflammatory
Antipyretic

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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

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Multimodal includes _____ acting anesthetics agents and _______ sparing components.

short acting; Opioid sparing.

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Celecoxib (Celebrex), Rofecoxib (Vioxx), Valdecoxib (Extra), Parecoxib (Dynastat) are all examples of what?

COX-2 Selective NSAIDs

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Do COX-2 selective NSAIDs effect platelets?

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Because COX-2 selective NSAIDs have no effect on platelets, this would increase the chance of what pathology?

Clotting (think MI and CVA)

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COX-2 selective and nonspecific inhibitors have _____________ analgesia

Comparable

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What was the first COX-2 inhibitor that decreases PG synthesis?

Celecoxib (Celebrex)

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What is the dosage for Celebrex?

200 to 400 mg PO QD

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Celebrex reaches its peak in…

3 hours

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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.

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What is the pain response pathway? (5)

(this was in the pain pathway slide set too)

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What are the 2 classes of opioids?

1) Phenanthrenes (L-isomers have opioid activity; morphine, codeine)

2) Benzylisoquinolones (Lack opioid activity; Papaverine, noscapine)

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What drug class does Ondansetron fall into?
What was it first developed for?
What CYP450 is relevant to ondansetron?

It is the first 5-HT3 antagonist
-It was approved for CINV
-Responsiveness decreased by variations in the CYP2D6 activity!

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Ondansetron is equivocal to what two drugs in its treatment of N/V?

Droperidol & Metoclopramide

(Slide 51)

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What are the side effects of Ondansetron?

HA, Constipation, and some QT prolongation!

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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

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What is the MOA of Corticosteroids in the treatment of N/V?

Why are Corticosteroids used with 5-HT3 (Ondansetron) & droperidol?
Hint: It was studied in CINV!

MOA is unknown: It works on glucocorticoid receptors in Nucleus Tractus Solitarius (NTS).
Corticosteroids potentiate 5 HT3 antagonists and droperidol!

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What is the dose for Dexamethasone (Decadron)? What is the MOA of Dexamethasone (Decadron)?

4 - 8 mg IV MOA: Anti-inflammatory; inhibition of phospholipase and cytokines and stabilization of cellular membrane.

What is the delay of onset of Dexamethasone (Decadron)? How long does efficacy persist? Are there any adverse effects of a single dose of Dexamethasone (Decadron)? What occurs if it is pushed fast?

- Onset: 2 hours. Efficacy: 24 hours. - Nope - Perineal burning/itching

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!!!

Multidose lidocaine vials are used for _____.

infiltration or peripheral nerve block.

Lidocaine is an ______ structure local anesthetic. Which drug is an exception to the amide/ester rule?

- Amide (amides anesthetics have 2 "i"s) - Cocaine. Cocaine is also local amide anesthetic.

How is lidocaine metabolized?

Liver

What is the IV bolus and infusion dose of lidocaine? When should the infusion be terminated?

- 1 to 2 mg/kg IV bolus over 2-4 min. - 1 to 2 mg/kg/hr infusion - Terminated within 12-72 hours.

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

For Preemptive Gabapentin, what patient population is it contraindicated for?

- MG and Myoclonus patients - Reduce dose in elderly patients

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

For Ofirmev, what is the Dose, Peak effect time, and duration?

What is the MOA for Ofirmev?

Reduces prostaglandin metabolites

What is the absolute contraindication for Ketorolac per Castillo?

Anaphylaxis reaction

For Ketorolac, what is the: - MOA - Peak - Dosing

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

What are some contraindications to consider when giving Toradol?

- Severe Renal impairment - Risk for bleeding - CAD - CABG - Pregnant - NSAID allergy

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

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

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: epinephrine will locally vasoconstrict and prevent lidocaine leakage into the intravascular space. (Castrater)

How is lidocaine overdose treated?

Lipid rescue

Which patients receive magnesium sulfate most often per Castillo?

Preeclamptic & eclamptic OB patients.

This med has anti-nociceptive effects by antagonizing the NMDA receptor and "probably" potentiates opioids centrally and peripherally.

Magnesium

Mg++ regulates which four cellular functions?

- Ca++ access intracellularly. - Neurotransmission - Cell signaling - Enzyme function

Which ion has limited movement across the BBB?

Mg⁺⁺

What conditions are contraindicative for magnesium administration?

Myasthenia Gravis & Renal Failure

What adverse side effects could occur with Mg++?

Hypotension, bradycardia, ataxia, somnolence, decreased muscular tone.

What is Mg⁺⁺ dosing for the following two situations? Preop: Intraop:

- Preop: 50 mg/kg IV - Intraop: 8 mg/kg/hr IV

What opioid requirement does the use of Mg++ significantly decrease?

Fentanyl

Ibuprofen: - MOA - Contraindications - Dose - Peak - Excretion

- COX 1 & 2 Inhibition = ↓ PG synthesis - Nephropathy, CABG, bleeding disorders, wound healing - 200 - 800 mg QD - 1-2 hours - Urine & 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.

What is the MOA of gabapentin?

**GABA Analog actions:** - Blockage of VG Ca⁺⁺ channels - inhibits release excitatory neurotransmitters - Descending inhibitory tract enhancement

Is gabapentin lipid soluble? What percentage protein-binding occurs with gabapentin? What’s it’s E 1/2 time?

- Yes; Lipid soluble - 0% (not protein-bound) - Brief E 1/2 time

Does gabapentin have any drug-drug interactions?

No drug interactions

What are indicated uses for gabapentin?

- Seizures - Neuropathic pain - Chronic pain syndromes.