Pharm exam II- opiods Flashcards
0
Q
What is the induction dose for Alfentanil?
A
50-300mcg/kg
think approx 150mcg/kg
1
Q
What is the induction dose for Morphine?
A
1mg/kg (titrated to 1mg/kg)
2
Q
What is the induction dose for Fentanyl?
A
5-40mcg/kg
Think approx 20mcg/kg
3
Q
What is the induction/loading dose for Remifentanil (Ultiva)?
A
0.5-1mcg/kg over 30 sec
Think approx 0.75mcg/kg
4
Q
What is the induction dose for Sufentanil?
A
2-10mcg/kg
Think approx 6mcg/kg
5
Q
What is the induction dose for Etomidate (Amidate)?
A
0.1-0.4mg/kg
Think approx 0.2mg/kg
6
Q
What is the induction dose for Ketamine (Kerolar)?
A
1-2.5mg/kg
Think approx 1.75 mg/kg
7
Q
What is the induction dose for Propofol (Diprivan)?
A
2-2.5mg/kg
8
Q
What is the induction dose for Methohexital (Brevital)?
A
1.5-2.5mg/kg
Think approx 2mg/kg
9
Q
What is the induction dose for Thiopental (Pentothal)?
A
3-5mg/kg
Think approx 4 mg/kg
10
Q
What is the induction dose for Diazepam (Valium)?
A
0.3-0.5mg/kg
Think 0.4mg/kg
11
Q
What is the analgesic dose for Ketamine (Kerolar)?
A
0.5-1mg/kg
12
Q
What is the analgesia dose for Afentanil (Afental)?
A
250-500mcg
or
5-10mcg/kg
(Think 375mcg or 7mcg/kg)
13
Q
What is the analgesia dose for Fentanyl?
A
0.7-2mcg/kg
Think 1mcg/kg
14
Q
What is the analgesia dose for Meperidine (Demerol)?
A
25-100mg
12.5-25 for post-op shivers
15
Q
What is the analgesia dose for Acetaminophen (Tylenol) IV?
A
1000mg IV q6hr (give infusion over 15min)
650mg IV q4hr
16
Q
What is the analgesia dose for Morphine?
A
2-15mg
titrate in increments of 1-2mg doses
17
Q
What is the analgesia dose for Ketorlac (Toradol)?
A
15-30mg q6hr
18
Q
What is the analgesia dose for Hydromophone (Dilaudid)?
A
0.2-0.6mg IV (q2-3hrs)
19
Q
What is the infusion dosing for Sufentanil?
A
0.1-0.5mcg/kg/min
Think approx 0.3mcg/kg/min
20
Q
What supplement bolus dose would you give for Sufentanil?
A
0.6mcg-4mcg/kg
Think 2mcg/kg
21
Q
What is the infusion dosing for Remifentanil (Ultiva)?
A
0.05 - 2mcg/kg (supplemented with prop, N2O, or Forane because such short acting)
(Think approx 1mcg/kg)
22
Q
What is the infusion dosing for Propofol (Diprivan)?
A
20-75mcg/kg/min (titrate to response)
23
Q
What dosage would you give for a Propofol bolus for sedation?
A
25-50mg
or
0.5 - 1mg
24
What is the infusion dosing for Methohexital (Brevital)?
50-150mcg/kg/min
| Think approx 100mcg/kg/min
25
What is the TIVA dose for Propofol?
100-200 mcg/kg/min
26
What is the TIVA dose for Fentanyl?
50-150mcg/kg
27
What is the TIVA dose for Sufentanil?
10-30mcg/kg
28
What is the induction dose for Midazolam (Versed)?
0.1-0.2mg/kg
29
What is the sedation dose for Midazolam (Versed)?
0.5 - 5mg (titrated)
30
What is the infusion dosing for Midazolam (Versed)?
0.25 - 5mcg/kg/min
| Think approx 2mcg/kg/min
31
What dose of Versed would you give to stop a seizure?
2-5mg
32
What Lorazepam (Ativan) dose would you give?
0.5 - 1mg
33
What is Clonidine when considering receptor type to cause its effects?
Alpha 2 agonist (presynaptic = neg feedback)
34
What effects can be seen with Clonidine?
Analgesia (useful to augment morphine and LA blocks)
Sedation (hyperpolarizes A2 receptor)
bradycardia
hypotension
35
What is a N-methyl-D-aspartate receptor?
It is the receptor that glutamate binds to to cause excitatory pain response
36
How does Ketamine cause it analgesic effects?
- It is a noncompetitive antagonist at the NMDA receptor which blocks glutamate and pain transmission
- Also interacts with mu, delta, and kappa opiod receptors
37
What type of surgical case should ketamine not be used during?
Neuro cases because it can cause increased cerebral blood flow, increased ICP, and increased CMR02, myoclonus, nystagmous, and seizure-like activity.
38
What can you pretreat a patient with to prevent some of the CNS/Delirium side effects of Ketamine?
Benzo's such as versed
39
Which cyclooxygenase enzyme would you want to block to prevent unwanted side effects found in many NSAIDs?
COX2 (ex- Celebrex is a COX2 inhibitor and will not cause decreased platelet aggregation, renal dysfunction, and GI ulcers whereas nonselective COX inhibitors will have these side effects)
40
What are some of the effects of NSAIDs?
- Decreased pain receptor activation from prostaglandins
- Reduced inflammation
- Inhibition of platelet aggregation
- Inhibition of prostaglandin formation causing reduced protection of GI tract and renal function
41
How does regional blockades or wound infiltration with local anesthetics prevent pain?
They inhibit transmission of nerve impulses by blocking sodium channels. (This slows the rate of depolarization so that threshold is not reached and action potentials are not propagated)
42
What group of drugs can provide anti-inflammatory and analgesic properties to supplement anesthesia?
NSAIDs
43
What is the safest NSAID for pts with renal impairment?
Aspirin
44
What are the max daily doses for adults and peds of Acetominophen?
```
Adults = 4gm/day
Peds= 75mg/kg
```
45
What meds should you be cautious of when considering liver toxicity from Acetaminophen?
opiod-nonopioid compounds containing acetaminophen
46
Is Ibuprofen a selective or nonselective COX inhibitor?
nonselective (therefore unwanted side effects= bleeding, ulcers, kidney failure)
47
What type of NSAID is Ketorolac (Tordal)?
Nonselective COX inhibitor (will have unwanted side effects)
48
In comparison to morphine what does 30mg of Ketorolac equivalent to?
9mg morphine
49
What patient populations would you not want to use Ketorolac (NSAIDs)?
- Asthmatics
- Renal impairment
- Post-op bleeding concerns
50
What is recommended length of use for Ketorolac when considering renal impairment?
no longer than 5 days
51
What type of NSAIDs can cause cardiac toxicity?
COX-2 selective agents
52
Which two NSAIDS should not be taken together to prevent cardiac toxicity?
Aspirin and Ibuprophen
53
How do opioid receptors cause analgesic effects?
- agonists pre-synaptic (A2 neg feedback=decrease Ca++= decrease NT)
- agonist post synaptic (inhibits membrane depolarization)
54
What side effects are seen with opioid agonist activity (A2 neg feedback)?
- Analgesia
- Sedation
- Miosis (pinpoint pupils)
- Bradycardia
- Resp depression
- Euphoria/Dysphoria
55
Where can opioid receptors be found?
Supraspinal=brain
| Spinal= Spinal cord (dorsal horn)
56
Supraspinal analgesia is mediated by which opioid receptors and which one one is most important?
- All opioid receptors except Mu-2
| - Mu-1 is most important in the brain
57
Spinal analgesia is mediated by which opioid receptors and which one is most important?
- All opioid receptors are found in the spinal cord
| - Mu-2 is most important
58
Which opioid receptor is more important in the periphery?
Delta receptors
59
Which opioid receptor does not contribute to dependence?
Kappa
60
What does neuraxial analgesia refer to?
Opiates given via Epidural or Spinal (intrathecal) methods
61
Neuraxial analgesia from opioids have same potential side effects as any other route but which side affects seem to be increased?
Pruritis and urinary retention (> than when given IV route)
62
Why are smaller doses used when a spinal (intrathecal) opiate is given compared to epidural dose?
Venous plexus in epidural space causes systemic absorption
63
What CNS effects can be seen with morphine-like opioids?
- Analgesia
- Euphoria (when in pain)
- dysphoria (when not in pain)
- Sedation
- Resp depression
- **decreased stress response to surgical stimulation (incision)
- **decreased MAC of volatile agents (ED50 of gas)
64
What GI effects can be seen with morphine-like opioids?
- Biliary tract-spasm of sphincter of odi
- Delayed gastric emptying (constipation)
- N&V
65
What meds are used to treat biliary sphincter of Odi spasm?
Narcan
Glucagon 2mg
66
What GU effects can be seen with morphine-like opioids?
- Urinary retention (Antidiuretic effect)
| - Increased detrussor muscle tone and sphincter tone
67
What cutaneous effects can be seen with morphine-like opioids?
- vessel dilation
- localized histamine (non-allergic) release = decrease bp
- Pruritis
- Erythema
68
Do morphine-like opioids cross the placenta/BBB?
Yes, morphine (most lipophobic opiod) less than Phenylpiperidines (more lipid soluble)
69
What meds can be given for pruritis from opioids?
Nubain
Zofran
Prop 10mg
70
How is morphine metabolized?
Conjugation in the liver
71
How is morphine excreted?
Mainly Kidney
| Biliary (7-10%)
72
What is important to consider when thinking about morphine metabolism and patients with kidney failure?
Morphine has active metabolites (morphine-3-etheral sulfate, morphine-3-glucuronide, morphine-6-glucuronide) which can cause prolonged sedation in renal pts
73
What is Codeine metabolized into?
Morphine
74
Fentanyl is how much more potent than morphine?
100 x's
75
Which is more lipid soluble morphine or fentanyl?
Fentanyl
76
What is fentanyl's DOA compared to morphine?
Fentanyl is DOA is shorter
77
What is Fentanyl's elimination time compared to morphine?
It is longer due to fentanyl's large Vd and lipid solubility.
78
Why does fentanyl have a rapid onset?
Rapid passage of BBB due to highly lipid soluble
79
Which med is more protein bound and has a smaller Vd because of it? Fentanyl or Sufentanil
```
Sufentanil = 92% protein bound small Vd
Fentanyl= 80-87% protein bound larger Vd than sufentanil
```
80
What is important to consider when thinking about fentanyl metabolism?
- metabolized in liver by D-methylation into somewhat active metabolite norfentanyl
- Significant first pass *pulmonary effect*
81
Fentanyl is excreted by kidneys and can be found present in urine for how long?
72 hrs.
82
What causes bradycardia that is sometimes seen with fentanyl?
marked depression of carotid sinus reflex
83
What are some important side effects to consider when thinking about fentanyl?
- Rigid chest
- less histamine release than (morphine)
- Slight increase in ICP
84
What meds would you give to treat rigid chest?
NDMR (give slow)
85
How much more potent is Sufentanil compared to Fentanyl?
10 x's
86
What side effects are commonly seen in Sufentanil?
Basically same as fentanyl:
-Brady, increased ICP, respiratory depression, rigid chest, decreased cmrO2
87
What opioids have first pass pulmonary uptake?
Fentanyl
| Sufentanil
88
Fentanyl is approximately how much more potent than Alfentanil?
10 x's
89
How is Alfentanil's context sensitive half time different than Sufentanil's and why?
It is longer due to its smaller Vd and less redistribution out of plasma
90
Alfentanil is more likely to cause what side effect in comparison to other phenylpiperdines?
Rigid chest
91
What types of surgical cases is Remifentanil commonly used?
Neuro cases (Dr's like to see pt awake shortly after surgery)
92
What is unique about Remifentanil?
It is ultra short acting due to its ester linkage which allows for hydrolysis by plasma/tissue
93
When comparing Remifentanil to Alfentanil and fentanyl what is its potency?
Remifentanil is about 15-20 x's more potent than Alfentanil and about the same potency as fentanyl
94
Since Remifentanil is hydrolyzed in the plasma so rapidly what characteristics does it have?
- Small Vd
- Easily titratable
- no cumulative effects
- rapid clearance
- Rapid recovery
- context sensitive half time approx 5 mins
95
Are the effects of Remifentanil affected by kidney and liver failure?
No, it is mainly metabolized via hydrolysis to an inactive metabolite and excreted by kidney
96
What should be considered postoperatively when Remifentanil is stopped?
Need to follow with longer acting analgesic because it does not provide post-op relief of pain
97
Why is Remifentanil not recommended as sole agent for surgery?
Uncertain loss of consciousness so usually supplemented with propofol, N2O, or forane.
99
Is Remifentanil used via neuraxial routes?
no, due to neurotoxicty caused
100
Meperidine (Demerol) is a synthetic opiate active mainly at which opioid receptors?
Mu and Kappa
101
What is the potency of Demerol compared to morphine**?
1/10th
102
What is important to consider about dosing when giving Demerol**?
- Should not be used >48hrs
| - Max dose is 600mg/24hrs
103
How is Meperidine metabolized?
It is extensively metabolized in the liver
104
Demerol's active metabolite normeperidine can cause what side effects?
CNS effects such as seizures by decreasing threshold
105
What other group of meds should not be given with Meperidine?
MAO inhibitors (can cause seizures and death)
106
What other side effects can be seen with Demerol?
Hyperpyrexia and dysphoria
107
What is Meperidine commonly used for?
Post-op shivers and L&D
108
How does Naloxone (Narcan) produce its effects at receptors?
It is a pure opioid antagonist at mu, delta, and kappa
109
How can Narcan be used with patients experiencing shock?
May reverse hypotension form endogenous endorphins
110
Where is Narcan metabolized
In the liver
111
Why is Narcan usually giving IV route?
First pass effect orally causes it to be 1/5th as potent
112
What effects/side effects can be seen with Naloxone (Narcan)
- Recurrence of pain
- N&V from rapid infusion
- *Pulmonary edema*
- Re-narcotization after med wears off
113
Narcan is supplied in 0.4mg/ml how would you draw it up to get 0.1mg/ml solution?
Draw up the 1ml of 0.4 solution with 3ml of NS
114
What is the oral opiate antagonist that lasts 24hrs?
Naltrexone
115
How is Nalmefene different than Narcan?
Its half time is 10hrs so its duration of action is longer due to slower metabolism by liver
116
What is Dilaudid mostly used for?
Post-op pain
117
What drug is better for renal patients Dilaudid or Morphine?
Dilaudid
118
What is a sedative?
Reduces anxiety, has calming effect with little or no effect on motor or mental function
119
What is a hypnotic?
Produces drowsiness, encourages the onset and maintenance of sleep
120
Opioid receptors are what type of receptor?
G-protein coupled receptor (intermediary in cell communication)
121
Extracellular binding of opioid to G-protein coupled receptor will cause what intracellularly?
Inhibition of adenyl cyclase
122
Which opioid receptor subsets add to dependence when activated?
Mu-2 & Delta
123
Is Remifentanil's duration affected when a person has a psuedocholinesterase deficiency (abnormality may be sensitive to certain anesthetic drugs such as muscle relaxants and ester local anesthetics)
No
124
What are some excitatory NT's (EPSP)?
- Acetylcholine
- NE at Alpha1 and Beta 1 (IPSP at Alpha 2)
- Serotonin (IPSP also at different sites)
- Glutamate
125
What NT's are inhibitory (IPSP)?
- Dopamine
- NE at Alpha 2 only
- Serotonin (in some receptors)
- GABA
- Nitric Oxide (?)
