Pharm B Test 2 Flashcards
1
Q
How does blocking alpha 2 receptors affect circulating levels of norepi
A
Blocking alpha2 blocks the reuptake of norepinephrine, thus increasing circulating levels of norepi
2
Q
1st generation non-selective beta blockers, such as propranolol, should not be given to which patients?
A
Asthmatics
3
Q
Effect of beta-1 activation on the heart
A
Increase HR, contractility, and conduction velocity
4
Q
Examples of beta-1 agonists (3)
A
- Dobutamine
- Dopamine
- Isoproterenol
5
Q
Examples of commonly used beta-1 specific antagonists (2)
A
- Metoprolol
- Esmolol
6
Q
Effect of beta-2 activation on blood vessels
A
Dilation
7
Q
Effect of beta-2 activation on bronchioles
A
Dilation
8
Q
Effect of beta-2 activation on uterus
A
Relaxation
9
Q
Effect of beta-2 activation on kidneys
A
Renin secretion
10
Q
Effect of beta-2 activation on pancreas
A
Insulin secretion
11
Q
Example of a commonly used beta-2 agonist
A
Albuterol
12
Q
Effect of alpha-1 activation on blood vessels
A
Constriction
13
Q
Effect of alpha-1 activation on pancreas
A
Inhibits insulin secretion
14
Q
Effects of alpha-1 activation on intestines/bladder
A
Constriction
15
Q
Example of alpha-1 agonist
A
Phenylephrine
16
Q
Examples of alpha-1 antagonist (3)
A
- Prazosin
- Phentolamine
- Labetolol
17
Q
Effect of alpha-2 activation on pre-synaptic sympathetic nerve endings
A
Inhibit norepinephrine release
18
Q
Alpha-2 affects the central nervous system by increasing conductance of which electrolyte
A
K+
19
Q
Effect of alpha-2 activation on platelets
A
Aggregation
20
Q
Examples of alpha-2 agonists (2)
A
- Clonidine
- Dexmedetomidine
21
Q
Examples of alpha-2 antagonists (2)
A
- Yohimbine
- Phentolamine
22
Q
Clinical uses for alpha antagonists
A
- Pheochromocytoma
- CHF
- Benign prostatic hypertrophy
- Raynaud’s phenomenon
23
Q
Effect of a-2 blockade on sympathetic NS
A
Increases sympathetic outflow and increases the release of norepi from nerve endings
24
Q
MOA of alpha antagonists
A
Binds selectively to alpha receptors and blocks activity of catecholamines at receptor sites
25
Side effects of alpha antagonists
1) Orthostatic hypotension and syncope
2) Reflex tachycardia
3) Impotence
26
What is phentolamine
Competitive non-selective alpha blocker
27
Clinical uses for phentolamine
Acute hypertensive emergencies that can be seen in patients with pheochromocytoma or autonomic hyperreflexia
28
Effects of phentolamine due to its effects on alpha-1 receptors
- Decrease in systemic BP due to direct action on vascular smooth muscle
- Reflex tachycardia
29
Effects of phentolamine due to its effects on alpha-2 receptors
- Increases release of NE
- Increase HR and CO
- Abdominal pain/diarrhea
30
What is Prazosin
Alpha 1 selective blocker
31
Which vessels are affected by Prazosin
Both arterioles and veins are dilated by Prazosin
32
How is Prazosin used preoperatively?
Used to treat pre-op BP in patients with pheochromocytomia
33
Prazosin is commonly taken by patients with what diseases? (3)
- Pheochromocytoma
- Raynauds
- BPH
34
What drug class does Terazosin (Hytrin) belong to?
Alpha1 blocker
35
What drug class does Tamulosin (Flomax) belong to?
Alpha1 blocker
36
Tamulosin (Flomax) acts preferentially on alpha-1 receptors located where?
- Vesical trigone muscle
- Urethra
- Prostate
37
Tamulosin (Flomax) is primarily used to treat which disease?
BPH
38
What is Yohimbine
Selective alpha2 antagonist
39
How does Yohimbine work to increase BP
Causes increased release of NE
40
Clinical uses for Yohimbine
- Idiopathic orthostatic hypotension
| - Impotence
41
What is Phenoxybenzamine
Non-competitive, irreversible, non-selective alpha blocker that is taken orally
42
Phenoxybenzamine has a greater effect on which alpha receptor?
Alpha-1
43
MOA of Phenoxybenzamine
Prevents inhibitory action of epinephrine on the secretion of insulin
44
Clinical uses for Phenoxybenzamine
- Orthostatic hypotension
| - Pre-op tx for patients with pheo and Raynaud's
45
Major sites of action for beta blockers
- Heart
- Smooth muscles of airway
- Smooth muscles of blood vessels
46
Should beta blockers be continued throughout the perioperative period?
Yes
47
In which surgery should you NOT give beta blockers or have patient's continue their beta blockers?
Aortic valve surgeries in which they are planning to pace them to 200+ bpm to decrease blood flow to the heart
48
What is the first med you should consider when you see new ST changes on an EKG during surgery?
Beta blocker
49
Cardiovascular uses for beta blockers
- Essential HTN
- Angina pectoris
- Acute coronary syndrome
- Cardiac dysrhythmias
- CHF
- Preop prep of hyperthyroid
50
Therapeutic uses for beta blockers (other than cardiovascular)
- Prevention of bleeding in portal hypertension
- Treatment of migraine, tremor, anxiety, alcohol addiction
- Treatment of glaucoma
51
What determines the receptor selectivity of beta blockers?
Dose - if you give enough esmolol, it can start blocking beta 2 also
52
Negative cardiovascular side effects from beta blockers
- Negative iontropy and chronotropy
- Decrease AV node conduction
- Accentuate AV block
53
Beta blockers can increase the concentration of which drugs/drug classes?
- Local anesthetics
| - Fentanyl
54
How do beta blockers affect MAC values?
Decreases MAC
55
Adverse effects of beta blockers on metabolism
- Increase in triglycerides
| - Hypoglycemia
56
Should patients who are lactating be given beta blockers?
No - it is contraindicated because they can cross into breast milk
57
Beta blockers can aggravate which pre-existing diseases?
- CHF
- Asthma
- AV blocks
58
How can beta blockers affect an anaphylactic reaction?
They can impair the body's response to epi
59
Prototype non-selective beta blocker
Propranolol
60
CV effects of Propranolol
Decrease heart rate, contractility, and cardiac output
61
Propranolol causes the retention of which electrolyte
Na+
62
Which beta blocker undergoes extensive first pass metabolism?
Propranolol
63
IV dose of propranolol
0.05mg/kg
64
Which non-selective beta blocker has a long duration of action
Nadolol
65
Which non-selective beta blocker is used to treat glaucoma and decrease IOP
Timolol
66
Which non-selective beta blocker prolongs cardiac action potential and can lead to v-tach
Sotalol
67
Which non-selective beta blocker is used to treat SVT
Sotalol
68
How do non-selective beta blockers affect diabetics
May potentiate insulin induced hypoglycemia due to beta-2 blockade
69
How do non-selective beta blockers affect asthma/COPD
Increases airway resistance
70
What is Metoprolol
B1 selective blocker
71
Dose of metoprolol
1-2mg
72
Concentration of metoprolol
1mg/ml
73
Which beta blocker is the MOST beta 1 selective?
Atenolol
74
Short acting beta-1 blocker
Esmolol
75
IV dose of esmolol
0.5mg/kg
76
Infusion dose of esmolol
0.1-0.3mg/kg/min
77
How is esmolol metabolized
Hydrolysis by plasma esterases
78
What is labetalol
Alpha1 antagonist and beta1/beta2 antagonist
79
Ratio of beta:alpha effects in oral labetalol
3:1
80
Ratio of beta:alpha effects in IV labetalol
7:1
81
CV effects of labetalol
- Decreases SVR (due to alpha1 activity)
- Decrease HR
- Blocks reflex tachycardia
82
Onset time of Labetalol
5-10minutes
83
IV dose of Labetalol
0.1-0.5mg/kg
84
Elimination half life of Labetalol
5 hours, hangs around for a long time
85
What is Carvedilol
Beta antagonist with alpha1 antagonist activity
86
Ratio of beta:alpha activity of Carvediolol
10:1
87
Clinical uses for Carvedilol
- Essential HTN
| - Symptomatic heart failure
88
Most common adverse reactions to Carvedilol
- Edema
- Dizziness
- Bradycardia
- Hypotension
- Nausea
- Diarrhea
- Blurred vision
89
What is Clonidine
Non-selective alpha agonist
90
What can be caused by acute withdrawal of clonidine?
Hypertensive crisis
91
Clinical uses for clonidine
- Hypertension
- Used in caudals and epidurals for post-op pain
- Anxiety
- Sleep aid
92
What is dexmedetomidine
Short acting alpha-2 agonist with anxiolytic, anesthetic, hypnotic, and analgesic properties
93
Dexmedetomidine is a good drug to use for what airway management?
Awake fiberoptic
94
What is the method of action of an alpha-2 agonist?
It stimulates the reuptake of norepi, thus decreasing circulating levels. It's a sympatholytic
95
2 main side effects of dexmedetomidine
- Hypotension
| - Bradycardia
96
Under what circumstances should dexmedetomidine be used with caution? (7)
1) Hypovolemia
2) Hypotension
3) Chronic hypertension
4) Elderly
5) Diabetes mellitus
6) Advanced heart block
7) Severe ventricular dysfunction
97
IV dose of dexmedetomidine
1mcg/kg over 10 minutes
98
Infusion dosing of dexmedetomidine
0.2-0.7mcg/kg/hour
99
If you don't start out with a bolus, how long will it take a dexmedetomidine infusion to reach effective plasma levels?
45 minutes to an hour
100
What are the benefits of dexmedetomidine over other available sedative agents?
- Lack of respiratory depression
- Decreases the need for opioid analgesics
- Less cardiovascular instability
101
IV dose of clonidine
4-8mcg/kg
102
Infusion dose of clonidine
2mcg/kg/hour
103
Epidural dose of clonidine
6-8mcg/kg
104
Intrathecal dose of clonidine
30-225mcg
105
A patient on chronic beta blockers must be given a beta blocker within __ hours of surgery
24
106
For cardiac cases, all patients must be given a beta blocker dose within __ hours of surgery
6
107
A beta blocker is contraindicated if the heart rate is below
50bpm
108
What is insulin?
A hormone secreted by pancreatic beta cells that causes the uptake of glucose into skeletal muscle and fat
109
Actions of insulin
- Carries glucose across cell membranes
- Increases synthesis of glycogen, protein, fatty acid (storage molecules)
- Decreases glycogenolysis, gluconeogenesis, lipolysis
110
Insulin is used for treatment of what electrolyte imbalance?
Hyperkalemia
111
How does insulin affect K+
Increases K+ entry into adipose and muscle tissue thus decreasing serum potassium levels
112
What other drug is given in combination with insulin to treat hyperkalemia?
Dextrose
113
What dose of insulin+dextrose is used to lower the serum K+ by 1meq/L?
10 units insulin + 25g dextrose
114
Level of serum K+ at which T wave abnormalities appear
5.5mEq/L
115
Level of serum K+ at which EKG intervals widen
6.5mEq/L
116
Level of serum K+ at which P wave changes start
7.0mEq/L
117
Level of serum K+ at which P waves disappear (atrial arrest)
8.8mEq/L
118
The EKG becomes a sine wave at what serum K+ level
9.0
119
What is the only type of insulin that is approved to be administered via IV route?
Humulin or Novolin (regular insulin)
120
Onset of regular insulin
30-60min
121
Duration of regular insulin
6-8hours
122
What percentage of regular insulin undergoes 1st pass metabolism by kidneys and liver?
50%
123
Basal rate of insulin production
1unit/hour (40unit/day)
124
Rapid acting insulin medication
Lispro
125
Short acting insulin medication
Regular insulin (CZI)
126
Intermediate acting insulin medication
Isophane (NPH)
127
Long acting insulin medication
Ultralente
128
What are the clinical uses for regular insulin?
- Hyperglycemia
- Hyperkalemia
- Ketoacidosis
129
Subcutaneous regular insulin is not reliable under what circumstances
- Peripheral edema
- Volume overload
- Temperature variations
130
When should you not use subq insulin?
- If there are expected electrolyte or acid/base changes during surgery
- Critically ill patients (they have variable tissue perfusion)
131
Why is ultralente insulin so long acting?
Because of the large particle size and crystalline form
132
By how much does 1 unit of insulin lower blood glucose levels?
25-30mg/dL
133
What is the normal calculation for insulin dosing units/hr?
(Glucose-100)/40
134
What calculation do we use in the OR to calculate the dosage of insulin in units/hr?
Glucose/150
135
Most serious side effect of hypoglycemia
Irreversible brain damage
136
Initial symptoms of hypoglycemia
- Diaphoresis
- Tachycardia
- Hypertension
137
Treatment options for severe intraop hypoglycemia
- 50-100ml of 50% glucose
| - 0.5-1.0mg glucagon
138
What is a side effect of using glucagon to treat hypoglycemia?
Nausea and vomiting
139
What diabetic medication should be held the day before surgery?
SGLT-2 inhibitors
140
What diabetic medications should be held the day of surgery for a minimally invasive surgery?
- Secretagogues
| - SGLT-2 inhibitors
141
Under what circumstances should ALL diabetic medications be held the day of surgery?
1. Reduced post-op oral intake
| 2. Extensive surgery with expected hemodynamic changes or fluid shifts
142
MOA of secretagogues
Stimulate beta cells to secrete insulin
143
Examples of secretagogues
- Sulfonylureas
| - Glinides
144
Examples of SGLT2 inhibitors
- Dapaglifozin
| - Canaglifozin
145
MOA of thiazolidnediones (TZDs)
Increase insulin sensitivity by acting on tissues to increase glucose utilization and decrease glucose production
146
2 currently available TZDs
- Thiazolidinediones
| - Pioglitazone
147
MOA of DPP-4 inhibitors (gliptins)
Increases levels of active glucagon-like peptide1 which increases insulin secretion and reduces glucagon secretion
148
MOA of biguanides
Decrease amount of glucose release into the bloodstream by the liver
149
MOA of SGLT2 inhibitors
Block the reabsorption of glucose in the kidneys thus increasing glucose excretion
150
Main example of a biguanide
Metformin
151
MOA of metformin
Inhibits gluconeogenesis in the liver and kidney
152
Side effects of metformin
1) Lactic acidosis
2) Anorexia
3) Nausea and diarrhea
153
You should use metformin carefully in which patients?
Patients with renal dysfunction
154
What blood molecule is an independent predictor for the development of cardiomyopathy and heart failure
Hemoglobin A1C
155
Normal A1C levels
Less than 6
156
Surgical goal for glucose levels in critically ill patients
110-180
157
Surgical goal for glucose levels in non-critically ill patients
140-180
158
What should be done if a patient is on an insulin pump on arrival to the hospital and their blood glucose is below 80
Turn off pump and correct per hypoglycemia protocol
159
What should be done if a patient is on an insulin pump on arrival to the hospital and their blood glucose is over 80?
Turn off pump and start VRII at basal rate
160
Insulin infusions should be considered when blood glucose levels are over
180
161
How should starting infusion rates for insulin be calculated
Glucose/100 (units/hr)
162
Units of insulin necessary for blood glucose of 181-200
2
163
Units of insulin necessary for blood glucose of 181-200 in insulin resistant patients
3
164
Units of insulin necessary for blood glucose of 201-250
3
165
Units of insulin necessary for blood glucose of 201-250 in insulin resistant patients
4
166
Units of insulin necessary for blood glucose of 251-300
4
167
Units of insulin necessary for blood glucose of 251-300 in insulin resistant patients
6
168
Units of insulin necessary for blood glucose of 300-350
6
169
Units of insulin necessary for blood glucose of 300-350 in insulin resistant patients
8
170
Units of insulin necessary for blood glucose over 350
7
171
Units of insulin necessary for blood glucose over 350 in insulin resistant patients
10
172
How often should glucose be checked if the patients glucose is under 100
Every 30 minutes until glucose is over 110
173
How often should glucose be checked if patients glucose is under 70
Every 15 minutes until glucose is over 70
174
Pharmacologic effects of Ca2+ channel blockers
- Decrease contractility
- Decrease heart rate by working at SA/AV node
- Decrease BP via vasodilation
175
3 classes of Ca2+ blockers
- Phenylalkylamines
- Dihydropyridines
- Benzothiazepines
176
Most commonly used phenylalkylamine
Verapamil
177
Examples of dihydropyridines
- Nicardipine
- Nimodipine
- Amlodipine
178
Most common benzothiazepine
Diltiazem
179
Clinical uses of Ca2+ channel blockers
- Coronary artery spasm
- Stable angina
- Cerebral vasospasm
- HTN
180
Which dihydropyridine Ca2+ blocker crosses the BBB
Nimodipine
181
How should Ca2+ blockers be administered to treat cerebral vasospasm
Intra-arterially
182
Which CCB also works on Na+ channels?
Verapamil
183
Actions of verapamil
- SA/AV node depression
- Negative inotropy
- Vasodilator
184
Clinical uses of verapamil
- Treatment of SVT
- Stable angina
- Essential HTN
- Maternal/fetal tachydysrhythmias
- Cerebral vasospasm
185
Actions of Nifedipine
- VASODILATION (main action)
| - Reflex tachycardia
186
Clinical uses of Nifedipine
- Angina
| - HTN emergencies
187
Actions of Nicardipine
- VASODILATION
- No SA/AV node action
- Minimal myocardial depression so good for patients with bad hearts
188
Most common concentrations of Nicardipine
100 or 200mcg/ml
189
Dose of Nicardipine infusion
5mg/hour
190
Clinical uses for Nicardipine
- Periop HTN
- Improving LV function during ischemia
- Coronary spasm
191
What is Nimodipine?
Lipid soluble analogue of Nifedipine that crosses the BBB
192
Clinical use of Nimodipine
Cerebral vasospasm
193
Actions of Diltiazem (Cardizem)
- Decreases AV node conductance
| - Coronary vasodilation
194
Clinical uses for Diltiazam (Cardizem)
- SVT
| - Essential HTN
195
How can CCBs affect the action of NMBs
Can prolong the effect
196
How can CCBs affect local anesthetics
Can increase the chance of local anesthetic toxicity
197
What is Clevidipine
Ultrafast acting 3rd generation dihydropyridine that vasodilates arterial
198
How must Clevidipine be administered
Infusion since the half life is so short
199
How is Clevidipine cleared
Plasma cholinesterase
200
Clinical uses for peripheral vasodilators
- HTN crisis
- Maintain controlled hypotension
- Improve LV stroke volume (CHF, regurgitant valves)
201
How do peripheral vasodilators work
Decrease systemic blood pressure by decreasing SVR via nitric oxide release
202
MOA of nitrovasodilators
Increase nitric oxide production, thus increasing cGMP production which causes vasodilation
203
How is nitric oxide inactivated
Binding to hemoglobin
204
Physiologic cardiovascular effects of nitric oxide
- Maintain basal PVR/SVR
- Distribute cardiac output
- Negative inotrope and chronotrope
205
Which part of the vasculature generates the most nitric oxide?
Arteries
206
Effects (other than cardiovascular) of nitric oxide
- Pulmonary vasodilation
| - Inhibits platelet aggregation
207
Negative effects that can stem from decreased levels of nitric oxide
- Essential HTN
- Atherosclerosis
- Vasospasm after SAH
208
Why does hypotension occur during septic shock?
Huge flood of nitric oxide is released
209
How do you avoid toxicity from inhaled nitric oxide?
Set fresh gas flows higher than minute ventilation
210
What is sodium nitroprusside
Iron molecule with 5 cyanide molecules that is an arterial and venous vasodilator
211
MOA of sodium nitroprusside
Produces nitric oxide which causes the vasodilation on VASCULAR tissue and reduces preload and afterload
212
Infusion dosing range for sodium nitroprusside
0.3-10mcg/kg/min
213
Over what infusion rate do you begin to see CN- accumulation
2mcg/kg/min
214
Potential toxicities associated with sodium nitroprusside
1) Cyanide
2) Thiocyanate
3) Methemoglobinemia
215
Pros of using SNP
- Short action
- Pulmonary dilator
- Effective for all HTNs
- Greater decrease in afterload than preload (at low doses)
216
Cons of using SNP
- Toxicity
- Light sensitive
- Vascular steal
- Ischemia
- Rebound HTN
- Increased ICP (headache)
- Inhibits platelet aggregation
- Decreased hypoxic pulmonary vasoconstriction
217
Side effect of giving SNP to awake patients
- N/V
| - Headache
218
Symptoms of cyanide toxicity
- Headache
| - N/V
219
Treatment options for cyanide toxicity
- Turn off infusion
- Sodium nitrite (or something that will clear the cyanide)
- 100% O2
- Bicarb (for the acidosis)
220
Why can thiocyanate toxicity occur with SNP administration?
Impaired renal clearance causes it to build up
221
Symptoms of thiocyanate toxicity
- Fatigue
- N/V
- Tinnitus
222
Treatment for thiocyanate toxicity
Dialysis
223
Clinical uses for SNP
- Controlled hypotension before cross clamp, aneurysm clip, etc
- Hypertensive emergencies (ruptured AAA, aortic dissection)
- Cardiac disease (CHF)
- Aortic surgery
224
What is nitroglycerin
A venous dilator
225
Effect of nitroglycerin on the heart
Decreases ventricular wall tension by decreasing preload
226
What percentage of sublingual nitroglycerin is subject to first pass metabolism
15%
227
MOA of NTG
Causes release of nitric oxide
228
Clinical uses for NTG
- Angina
- Cardiac failure
- Acute HTN
- Controlled hypotension (i.e. during cannula insertion)
229
What is hydralazine
An arterial dilator
230
Onset time for hydralazine
15 min - wait for it to work!
231
Duration of hydralazine
Several hours
232
Dosage of hydralazine
2.5-5mg every 15 minutes
233
Clinical uses for hydralazine
HTN
234
Side effects of hydralazine
- Reflex tachy
- Coronary steal
- Headache
- Flushing
- Angina
- Rash
- "Lupus like syndrome"
235
How does hydralazine affect blood flow to the uterus
Maintains it
236
When is papavarine used
To prevent spasm when vessels (i.e. LIMA) are harvested
237
What is adenosine
Endogenous nucleotide that is a potent coronary vasodilator with a very quick half life (0.6-1.5sec)
238
Clinical uses for adenosine
- SVT treatment
- Aneurysm clippings (slows C.O. for clip placement)
- Thoracic stents
239
What should you have available when administering adenosine
Pacing pads
240
What is trimethaphan
A ganglionic blocker that is a vasodilator
241
Dosing range for trimethaphan infusion
10-200mcg/kg/min
242
Side effect of trimethaphan
Blurry vision
243
MOA of ACE inhibitors
Inhibits the conversion of angiotensin I to angiotensin II thus decreasing SVR
244
Most common side effect of ACE-Is
Coughing
245
Most serious side effect of ACE-Is
Angioedema
246
ACE-Is are contraindicated in patients with what?
Renal artery stenosis
247
Patients on chronic ACE inhibitors may exhibit what during general anesthesia?
Exaggerated hypotension
248
How can the chance of exaggerated hypotension in patients on ACE inhibitors be decreased?
Have the patients stop them 12 hours before surgery
249
Benefits of inhaled nitric oxide
Improves pulmonary HTN without compromising systemic pressure
250
Dose of inhaled nitric oxide
10-40ppm
251
What is the current "go to" drug for pulmonary vasodilation?
Epoprostenol (Flolan)
252
What is Epoprostenol (Flolan)
Metabolite of arachadonic acid that is a potent vasodilator
253
Patient related risk factors for surgical site infections (SSI)
- Extremes of age
- Poor nutrition
- Obese
- DM
- Glucose control perioperatively
- Vascular disease
- Smoking
- Preexisting infections
- Altered immune system
- Corticosteroid therapy
- Preop skin prep
- Length of procedure
254
SCIP guidelines for when prophylactic antibiotics should be received
1 hour prior to incision
255
SCIP guidelines for when prophylactic antibiotics should be discontinued after general surgery
Within 24 hours
256
SCIP guidelines for when prophylactic antibiotics should be discontinued after cardiac surgery
Within 48 hours
257
SCIP guidelines for how long glucose should be monitored after cardiac surgery
24 hours
258
According to SCIP guidelines, after what surgeries should patients have immediate postop normothermia
Colorectal surgeries
259
Surgical techniques that can reduce chance of SSI
- Gentle traction
- Effective hemostasis
- Removal of devitalized tissues
- Obliteration of dead space with drains, suction
- Irrigation with saline
- Fine, non-absorbed sutures
- Wound closure without tension
260
Perioperative factors affecting incidence of SSI
- Body temp
- FiO2
- Fluid management
- Blood glucose
- Blood transfusion
- Antimicrobial prophylaxis
261
Benefits of normothermia in preventing SSIs
- Better wound healing
| - Less vasoconstriction
262
Why does hypothermia cause SSI
- Decreases tissue perfusion
- Decreases superoxide radicals
- Decreases collagen
- Induced anti-inflammatory profile
263
Why does hyperglycemia increase chances of SSI
- Decreases leukocyte count
- Decreases neutrophil function
- Deactivates immunoglobulines
264
What blood product has the highest risk of infection
Platelets
265
How can the risk of SSIs with blood transfusions be reduced
- Use autologous PRBCs
| - Use leukocyte reduced units
266
How often should repeat doses of antibiotics be administered?
Every 1-2 half lives
267
Which antibiotic classes are bactericidal?
Cephalosporins, aminoglycosides, fluoroquinollines, vancomycin, daptomycin, metronidazole
268
Which antibiotic classes are bacteriostatic?
Macrolides (erythromycin), tetracyclins, trimethoprim, sulfonamide
269
Clean procedures
Closed, elective procedures
270
Clean-contaminated procedures
GI/GU, biliary, re-operation within 7 days, lap appy
271
Contaminated procedures
Acute inflammation, penetrating trauma within last 4 hours
272
Dirty procedures
Preexisting infection, perforated GI, trauma from over 4 hours ago
273
MOA of cephalosporin
Inhibits cell wall synthesis
274
The efficacy of cephalosporins depends on...
The percent time above minimum inhibitory concentrations
275
How does the coverage against bacteria change as you move down the cephalosporin generations
As you get in later generations (3rd, 4th) there is more coverage against gram negative and less against gram positive
276
1st generation cephalosporins
- Cefazolin
| - Ceftezole
277
2nd generation cephalosporins
- Cefuroxime (Zinacef)
- Cefaclor
- Cefoxitin
278
3rd generation cephalosporin
Ceftizoxime
279
4th generation cephalosporins
- Cefclidine
| - Cefepime
280
Proper antibiotic and dose for clean procedures
Ancef 1-3 grams
281
Ancef dose for patients under 40kg
1 gram
282
Ancef dose for patients over 120kg
3grams
283
Proper antibiotic and dose for thoracic/orthopedic cases
Cefuroxime 1.5grams (2nd generation)
284
Antibiotic options and doses for bowel surgeries
- Cefoxitin 1-2 grams (2nd generation) with mycin
- Ancef 1-2g + flagyl 500mg
- Unasyn 3g
285
Antibiotic options and doses for PCN allergic patients
- 1gram vancomycin
| - 600-900mg clindamycin
286
Antibiotics that cover gram negative bacteria
- Gentamicin
- Ciprofloxacin
- Levaquin
- Aztreonam
287
MOA of vancomycin
Inhibits cell wall synthesis in most gram positive bacteria
288
Dosage of vancomycin
15mg/kg q12hr
289
Dose of vanc for patient under 90kg
1 gram
290
Dose of vanc for patient over 90kg
1.5grams
291
Repeat dosing is beneficial in surgeries lasting over __ hours
7
292
Cases in which vancomycin is beneficial
- Prosthetic heart valve
| - Vascular graft
293
Antibiotic used in neuro cases that must be re-dosed q2h
Nafcillin
294
Recommendation for antibiotics for neurosurgeries
1) 1-2g ancef
2) 1-2g nafcillin
3) 1g vanc if PCN allergic
295
Which neuro surgery is not clean?
VP shunt
296
In terms of clean/contaminated/dirty/etc.- what is carotid surgery?
Clean
297
In terms of clean/contaminated/dirty/etc.- what is tonsil/oropharynx surgeries?
Clean-contaminated
298
Recommendation for antibiotics in clean-contaminated head/neck surgeries
1) 1-3g ancef
| 2) 600-900mg clinda + 1.5mg/kg gent
299
In which cardiac surgery should you consider adding antibiotics to cover gram - bacteria?
Saphenous vein harvest
300
Antibiotic of choice for cardiac surgery
Cefuroxime (2nd gen)
301
Oral antibiotic regimen that most patients take before having colorectal surgery
Neomycin + erythromycin or flagyl
302
IV regimen options for colorectal surgery
1) 1-2g ancef + 500mg flagyl
2) 1-2g cefoxitin or cefotetan (2nd gen)
3) 3g ampicillin-sulbactam (Unasyn)
303
Gentamycin dose
1.5-2mg/kg
304
Antibiotic options for PCN allergic patients coming in for colorectal surgery
1) Clindamycin + a "floxacin"
| 2) Flagyl + aztreoname + gent
305
Antibiotic recommendations for normal lap appy/GI case
1) 1-2g ancef
| 2) 3g Unasyn
306
Antibiotic recommendation for ruptured lap appy
2g ancef + 500g flagyl
307
Antibiotic options for PCN allergic patients coming in for GI case
Clinda + gent
308
Antibiotic for esophageal/gastroduodenal surgery
1-2g ancef
309
Antibiotic for biliary tract
1-2g ancef
310
In which orthopedic cases should antibiotics be considered
- Hip repair
- Joint replacement
- Fixation
311
Antibiotic options for C-section
1) 1 dose of ancef before incision
| 2) Clinda + gent
312
Antibiotic recommendation for clean GU procedures (i.e. nephrectomy)
Ancef
313
Antibiotic recommendation for clean-contaminated GU procedures (bladder reconstruction)
Aminoglycoside + flagyl or clinda
314
Antibiotic recommendations for vascular surgeries
1) Ancef
| 2) Vanc + gentamycin 2mg/kg
315
Antibiotic for a patient coming in with infected aorto byfem
Vanc
316
Which timing of antibiotic administration was found to have the least incidence of SSI?
Preop (0-2hrs before incision)
317
Which timing of antibiotic administration was found to have the highest incidence of SSI?
Early (2-24hrs before)
318
How does SBE form?
1) Formation of non-infected thrombus
2) Infection of thrombus
3) Proliferation of bacteria
319
High risk factors for SBE
1) Prosthetic heart valves
2) History of IE
3) Cyanotic congenital heart disease
4) Surgically constructed systemic and pulmonary conduits
320
Moderate risk factors for SBE
1) Bicuspid aortic valve
2) Acquired valvular dysfunction (AS, MS)
3) Hypertrophic obstructive cardiomyopathy
4) Mitral valve prolapse with regurg on auscultation
321
Low risk factors for SBE
1) Murmurs
2) Isolated ASD
3) Repair of ASD/VSD/PDA
4) MVP without regurg
5) MR
6) Sclerotic aortic valve
7) Mild TR
8) CAD
9) Rheumatic fever
10) Pacemaker
11) Stent
322
Recommendation for antibiotics for SBE prophylaxis
1) 2g ampicillin
| 2) 1.5mg/kg gentamicin for GI and GU
323
Max dose of gentamicin for SBE prophylaxis
150mg
324
Recommendation for antibiotics for SBE prophylaxis in PCN allergic patients
- 600mcg clinda
- 1g ancef
- 1g vanc
325
Negative side effect of vancomycin and symptoms
Redman syndrome - pruritus, flushing, erythema, hypotension
326
Negative side effect of gentamicin
Ototoxicity
