Multimodal - test 2 Flashcards
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
Non-specific or COX-2 selective? Ibuprofen, naproxen, aspirin, acetaminophen, and ketorolac
Non-Specific - increased gastric irritation with these
Multimodal includes _____ acting anesthetics agents and _______ sparing components.
short acting; Opioid sparing.
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
Because COX-2 selective NSAIDs have no effect on platelets, that increase the chance of what two disease processes?
MI and CVA
COX-2 selective and nonspecific inhibitors have _____________ analgesia
Comparable
What was the first COX-2 inhibitor that decreases PG synthesis?
Celecoxib (Celebrex)
What is the dosage for Celebrex?
200 to 400 mg PO QD
Celebrex reaches its peak in…
3 hours
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.
What are the 2 classes of opioids?
1) Phenanthrenes (L-isomers have opioid activity; morphine, codeine)
2) Benzylisoquinolones (Lack opioid activity; Papaverine, noscapine)
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
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
What is the MOA of Corticosteroids? Why are Corticosteroids used with 5-HT3 (Ondansetron) & droperidol?
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)?
8 to 10 mgs
MOA: Anti-inflammatory; inhibition of phospholipase and cytokines and stabilization of cellular membrane.
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
With diabetics one dose will not throw off their blood sugar levels.
If you push it to fast you are going to give them a burning booty
According to the TXWES medication guide, what are the doses for Acetaminophen (Ofirmev), Ketorlac (Toradol), & Ibuprofen (Caldor).
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
What kind of properties does propofol have?
Analgesic properties
Ketamine inhibits _____ activation.
NMDA
What is the induction dose of Ketamine?
0.5-1.5 mg/kg/IV
4-8 mg/kg IM
What is the maintenance dose of Ketamine?
0.2-0.5 mg/kg IV analgesia
4-8 mg/kg IM
What is the subanesthetic (analgesic dose) of ketamine?
0.2 -0.5 mg/kg IV
What is Post op sedation and analgesia dose for ketamine?
1-2 mg/Kg/hour (pediatric cardiac surgery)
What is neuraxial analgesia dose of Ketamine?
30mgs Epidural
5-50 mg in ml of saline intrathecal/spinal/subarachnoid.
Which concentration lidocaine do we use as CRNA?
A bag of 2g lidocaine with concentration of 4mg/ml.
Multidose lidocaine vial is used for _____
infiltration or peripheral nerve block.
Lidocaine is _____ local anesthetic
Amide Amide (amides anesthetics have 2 “i”s). Except for cocaine. Cocaine is also local amide anesthetic.
How is lidocaine metabolized?
liver
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.
Regarding Gabapentin’s preemptive analgesia, what 3 studies/procedures is it used in?
Spine surgeries, Orthopedic procedures, major abdominal procedures.
What is the PO dose of preemptive Gabapentin? When should we give it? What is its 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 - reduce dose in elderly.
What are Gabapentin’s side effects?
- Somnolence,
- fatigue,
- ataxia,
- vertigo,
-GI disturbances: constipation, - abrupt withdrawal in seizure pts (when Gaba is used as an antiepileptic): 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 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.
What are some contraindications to consider when giving Toradol?
- Severe Renal impairment,
- Risk for bleeding,
- CAD,
- CABG,
- Pregnant,
- Elderly (decrease dose),
- NSAID allergy.
Lidocaine plasma concentration of ____ causes what?
1-5 mcg/ml = ?
5-10 mcg/ml = ?
1-5 mcg/ml = analgesia.
5-10 mcg/ml = circum-oral numbness; tinnitus; skeletal muscle twitching; systemic HYPOtension; myocardial depression.
Lidocaine plasma concentration of ____ causes what?
These are OD levels
10-15 mcg/ml = Sz’s; unconsciousness.
15-25 mcg/ml = apnea (2/2 affecting the pons and medulla oblongata); coma.
Lidocaine plasma concentration of > 25 mcg/ml causes what? How do you treat it?
Cardiovascular depression - lipid rescue
Which procedure would you expect to see a high use of Lidocaine?
EGD’s.
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.”
Which pt’s do we give Magnesium to most often?
OB - eclampsia.
This med has anti-nociceptive effects by antagonizing the NMDA receptor and “probably” potentiates opioids centrally and peripherally.
Magnesium.
Mg++ regulates what?
- Ca++ access into the cell and actions within cell,
- Neurotransmission,
- Cell signaling,
- Enzyme function.
Mg++ has _______ passage across the ___. C/I for Mg++ include __________ ______ and _____ failure.
limited; BBB.
Myasthenia Gravis and Renal failure.
What S/E should we monitor for with Mg++?
Hypotension, bradycardia, ataxia, somnolence, delayed movement, decreased muscular tone.
Mg++ dosing 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
Using multimodal anesthesia, what 2 meds might we give in preop to better control pain later?
Acetaminophen 1000 mg PO, Gabapentin 300 mg PO.
With non-opioid anesthesia, what medications are used for induction?
Proposal, Lidocaine, Ketamine, volatile anesthetics. Paralytic if needed.
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.
What meds are given post op to control pain using multimodal anesthesia?
PO dosing of Tylenol, Magnesium, Gabapentin, Celebrex or Advil.
-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 VG Ca channels, inhibits release of glutamate and excitatory neurotransmitters, enhances descending inhibition.
Is gabapentin lipid soluble? How much does it like proteins? What’s its E 1/2 time?
Yes Lipid soluble.
NOT protein bound.
Brief E 1/2 time.
Does gabapentin have any drug-drug interactions?
NO! It’s friendly with other drugs.
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.
