Neuropsych Objectives Deck

Question 1

Serotonergic system

Answer 1

Conversion:
Tryptophan to 5-HT (serotonin)- released via vesicles to 5-HT receptor

Question 2

Noradrenergic system

Answer 2

Conversion:
Tyrosine to DOPA to DA to Norepinephrine

Packaged in vesicles and released to bind adrenergic receptors_ a-1 a-2 beta-1 and beta-2

NE metabolism in the synapse is via MAO or COMT (catechol-O-mthyltransferase

Question 3

Dopaminergic System

Answer 3

Dopamine is intermediary in synthesis of norepi- so similar cascade but with dopamine transporters and receptors

Question 4

Tricyclic antidepressants

MOA
Kinetics
Adverse effects/Anesthesia implications

Answer 4

Pre and post synaptic effects on receptors or serotonin and norepinephrine

Large Vd, 50% first pass, hepatic metabolism

Anticholinergic effects
Increased arrhythmogenicity
Tachycardia/prolonged Qt

Exaggerated response to indirect acting sympathomimetics

Question 5

Selective Serotonin Reuptake Inhibitors

MOA
Kinetics
Adverse effects/Anesthesia implications

Answer 5

5-HTT inhibition

Hepatic metabolism, all have active metabolites
Half life ~24hrs

QTc prolongation
Inhibit platelet aggregation, increased bleeding
Serotonin syndrome-can mimic MH

Question 6

Monoamine Oxidase Inhibitors

Answer 6

Irreversible binding to MAO for about 2 weeks

Avoid tyramine

Can cause HTN crisis with ephedrine

Avoid phenylpiperidines (MEPERIDINE) due to weak serotonin reuptake inhibition

Question 7

First generation antipsychotics

Answer 7

Blockade of D2 receptors

Often used for anti-emetic or sedative effects

Ex.
Prochlorperazine (compazine)
Promethazine (phenergan)
Chlorpromazine (Thorazine)

Haloperidol (haldol)
Droperidol (Inapsine)

Metoclopramide (reglan)

Question 8

Extrapyramidal symptoms

Answer 8

Movement disorders
Dystonia
Akathesia
TD
Pseudoparkinsonism

Question 9

Dystonia

Answer 9

Acute head/neck spasms
Single dose
Reversible with Anticholinergic

Question 10

Akathesia

Answer 10

Restlessness
Single dose
Give Anticholinergic or benzo to quell anxiety

Question 11

Pseudoparkinsonism

Answer 11

Takes several weeks to develop
Generally responsive to anticholinergics

Don’t give dopamine antagonists in a dopamine disorder!!! Will exacerbate symptoms of Parkinson’s

Question 12

Tardive dyskinesia

Answer 12

Worm like movement
Typically from long term therapy
Often irreversible and anticholingerics may worsen
Same with D2 antagonists

Question 13

Neuroleptic Malignant Syndrome

Answer 13

Triggered by first generation antipsychotics

Hyperthermia, muscle rigidity, severe metabolic syndrome (acidosis/hyperkalemia), HTN/tachycardia, AMS

Rhabdo in severe cases

Dantrolene & supportive care

As well as dopamine agonists (bromocriptine)

Question 14

Neuromalignant Syndrome Vs Serotonin syndrome

Answer 14

NMS- takes time to develop (days instead of hours), diminished reflexes

SS- hyperreflexia

Question 15

Lithium

Adverse effects
Drug interactions
Anesthesia concerns

Answer 15

Narrow therapeutic index
Weight gain
DI
Nephro/neurotoxic

Increased blood levels of thiazide diuretics, ACEIs, ARBs and NSAIDs

Prolongs all paralytics, avoid NSAIDs

Question 16

Valproate (depakote)

Answer 16

Anticonvulsant

Hepatitis, pancreatitis
Thrombocytopenia and platelet dysfunction

Increased metabolism of NMBDs

Question 17

Carbamazepine (tegretol)

Answer 17

Anticonvulsant

Hepatic, strong CYP inducer

Stevens-johnson syndrome (toxic epidermal necrolysis
SIADH (older adults)

Increased metabolism of NMBDs and midazolam/fentanyl/methadone/tramadol

Question 18

Lamotrigine (lamictal)

Answer 18

Anticonvulsant

Sedation/dizziness
Severe dermatological reactions
Blood disorders

Increased sedation and increased metabolism of NMBDs

Question 19

Amphetamine MOA/anesthesia considerations

Answer 19

Withdrawal syndrome if stopped abruptly

Unpredictable response to sympathomimetics-give direct acting -eg. vasopressin

May require more sedation

Question 20

Levodopa

MOA
Kinetics
Anesthesia Implications

Answer 20

It is converted to dopamine within the CNS

Administered with AAAD inhibitor (carbidopa) to prevent dopamine accumulation in periphery

MUST BE CONTINUED during perioperative period, discuss schedule with patient-consider NG-instruct them to bring it with them to hospital

Question 21

COMT inhibitors

Answer 21

Helps prevent metabolism of levodopa-prolongs action in PD patients

Question 22

Pramipexole

MOA
Kinetics
Implications

Answer 22

Agonism of dopamine receptors

Excreted in urine up to 90% unchanged

Used as adjunct

No significant implications for anesthesia with a relatively long half-life

Question 23

MG anticholinesterases evaluation/treatment

Answer 23

Edrophonium may be used for diagnostics due to short half-life

Pyridostigmine most often used to treat due to prolonged half-life

Interfere with NMBDs, prolong succ

Question 24

Common anti muscarinic adverse effects with antidepressants

Answer 24

Xerostomia (dry mouth)

Urinary hesitancy

Decreased gastric motility

Blurred vision

Question 25

Common MAOIs

Answer 25

Isocarboxazid
Linezolid
Methylene blue
Moclobemide
Phenelzine
Procarbazine
Rasagiline
SELEGILINE
Tranylcypromine

Question 26

What states of a receptor can local anesthetics bind?

Answer 26

Open and inactivated states

NOT closed

Question 27

Tertiary amines are selective for?

Answer 27

Serotonin

Question 28

Secondary amines are selective for?

Answer 28

Norepinephrine

Question 29

Which class of psych drugs do you stop 2 weeks before surgery?

Answer 29

Psych!

Don’t stop them work around them

Question 30

What antiemetic agents do you avoid in Parkinson’s?

Answer 30

Dopamine antagonists!!

Question 31

Which local is most cardio toxic?

Answer 31

Bupivacaine

Question 32

Which psych drugs will cause an exaggerated response to ephedrine?

Answer 32

TCAs and MAOIs

Question 33

Which drugs will cause there to be a blunted response to administration of ephedrine?

Answer 33

Methylphenidate and amphetamines

Question 34

How many mls of 0.1% Bupivacaine can I give to a 95 kg patient?

Answer 34

Do the math bitch

Question 35

Considerations in Myasthenia Gravis

Answer 35

-increased sensitivity to non-depolarizing NMBDs

Resistance to succinylcholine