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Semester 4 TxWes > Pharm Flashcards > Flashcards

Pharm Flashcards

1
Q

What inhaled gas provides analgesia?

A

NO

all the others such as Sevo do NOT provide analgesia

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2
Q

T/F: The exact MOA of inhaled anesthetics is known/agreed upon

A

False

Inhaled anesthetics produce immobility via actions on the spinal cord [Campagna JA et al. N Engl J Med 348: 2110, 2003]. There is consensus that inhaled anesthetics produce anesthesia by enhancing inhibitory channels and attenuating excitatory channels, but whether or not this occurs through direct binding or membrane alterations is not known. [Miller]

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3
Q

At what MAC do 95% of patients not respond to surgical incision?

A

1.2 MAC

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4
Q

At what MAC do 99% of patients not respond to surgical incision?

A

1.3 MAC

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5
Q

How much MAC of Sevoflurane would you use if your goal was 1.4 MAC and you planned to concurrently administer 0.5 MAC of NO?

A

0.9 MAC of Sevo

According to “rat” data, MAC values are additive in terms of preventing movement to incision (0.5 MAC of nitrous oxide plus 0.5 MAC of isoflurane = 1.0 MAC of any other agent)

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6
Q

What color is associated with: Sevo, Des and Iso?

A

Des = Blue
Sevo = Yellow
Iso = Purple

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7
Q

What volatile anesthetic would be a good choice for rapid emergence for an obese patient?

A

Desflurane - because it has very low solubility it can be absorbed quickly and eliminated quickly

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8
Q

What VA can cause emergence delirium in kids?

A

Sevo

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9
Q

What VA is very lipid soluble, causing a longer emergence?

A

Iso

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10
Q

What factors increase anesthetic requirements?

A

Chronic ETOH, infant, red hair, hypernatremia and hyperthermia

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11
Q

At what age is MAC requirement the highest?

A

6 months

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12
Q

What factors decrease anesthetic requirements?

A

Acute ETOH, elderly, hyponatremia, hypothermia, anemia (generally Hgb less than 5), hypercarbia, hypoxia and pregnancy

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13
Q

What is the relationship of acute vs chronic ETOH in MAC requirements?

A

Chronic ETOH increases requirements, acute ETOH decreases it

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14
Q

Your mental trick to identifying what factors increase/decrease MAC requirements?

A

If it is something that makes the system more excitable (like hyperthermia/hypernatremia) you likely need more anesthetic, if it is something that decreases excitability (acute ETOH - you are already drowsy/altered, hypo-natremia/thermia) or reduces how much blood goes to the head (pregnancy)

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15
Q

Why does anesthetic gas require very small/careful titrations?

A

They are very potent with a very narrow TI/therapeutic window

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16
Q

T/F: VA experience little to no metabolism

A

True

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17
Q

Why is measurement of expired VAs important?

A

Because what we expire mimics what is in the brain at that given moment

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18
Q

1% solution is what concentration?

A

10 mg/ml

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19
Q

0.25% solution is what concentration?

A

2.5 mg/ml

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20
Q

1:200,000 is what concentration?

A

5 mcg/ml

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21
Q

1:10,000 is what concentration?

A

0.1 mg/ml

This is your standard epi concentration in the code cart

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22
Q

List the induction, sedation and TIVA doses for propofol

A

Induction = 2 mg/kg IV
Sedation = 25 – 100 mcg/kg/min
TIVA = 100 – 300 mcg/kg/min

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23
Q

T/F: propofol is a controlled substance

A

False

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24
Q

What conditions does the propofol dose need to be changed: elderly, AKI, or liver failure?

A

Elderly - Propofol dose rarely needs to be changed with renal/liver disease

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25
Q

What induction agent is a good choice for asthma patients?

A

Propofol - acts as a bronchodilator

ketamine is also a very potent bronchodilator

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26
Q

What IV agent is the best choice to suppress the SNS response to DL?

A

Propofol

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27
Q

Describe propofol infusion syndrome

A

Sudden onset of bradycardia that progresses to
asystole and is resistant to treatment.

No antidote; expect the need for high dose pressors/inotropes

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28
Q

What induction agent requires GABA to be present in order to work?

A

Etomidate (it is a GABA modulator, it does NOT mimic GABA)

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29
Q

When is the imidazole ring water soluble? Lipid soluble?

A

Water = open ring
Lipid = closed ring

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30
Q

What is the standard concentration of etomidate?

A

0.2% or 2 mg/ml

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31
Q

What is the primary indication for etomidate? Contraindication?

A

Indication = CV instability
Contra = history of seizure or seizure risk, also adrenal insufficiency

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32
Q

Induction dose of etomidate?

A

0.3 mg/kg IV

Of note, earlier pharmacology lectures gave a range of 0.2 - 0.4 mg/kg IV

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33
Q

What induction agent has the highest incidence rate of PONV?

A

Etomidate (up to 30%)

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34
Q

T/F: Ketamine is a hypnotic

A

False: it causes dissociative anesthesia by providing profound analgesia and amnesia, but not hypnosis

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35
Q

What is the most common concentration of ketamine?

A

5% or 50 mg/ml

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36
Q

What is the induction dose of ketamine?

A

1.5 mg/kg IV

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37
Q

What is the intense analgesia dose of ketamine?

A

0.2 - 0.5 mg/kg

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38
Q

What is the “calm the kid” dose of ketamine?

A

4 - 8 mg/kg IM

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39
Q

What medications make up the “ketamine dart” to calm a child?

A

Ketamine, versed and robinol (other anti-cholinergic like atropine may be used)

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40
Q

Primary contraindication to ketamine?

A

If the patient is on a MAOI - can greatly increase circulating epi

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41
Q

Co-administration of what can help manage/reduce hallucinations when using ketamine?

A

Vitamin V! Or the lame version: Versed

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42
Q

T/F: the airway is considered protected with ketamine administration

A

False: it causes little direct respiratory depression (and keeps the laryngeal/pharyngeal reflexes intact), but because of the dissociation the airway is NOT considered fully protected

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43
Q

What are the 3 different a2 receptor subclasses (include their primary function)?

A

α2A: Sedation, Hypnosis, Sympatholysis
α2B: Vasoconstriction, Anti-shivering, Analgesia, Ca linked– may be excitatory
α2C: Learning, Startle response

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44
Q

Standard concentration and preparation of precedex?

A

0.1 mg (100 mcg) per ml in a 2 ml vial, mix with 48 cc of NS to get a working concentration of 4 mcg/ml

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45
Q

What is the loading dose and infusion rate of precedex?

A

lD = 1 mcg/kg over 10 minutes (too fast may cause HTN)

Infusion = 0.2 - 0.7 mcg/kg/hr

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46
Q

What induction/maintenance agent has an anti-sialagogue effect?

A

Precedex

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47
Q

Why is precedex so useful for drug/ETOH addicts?

A

It offsets withdrawal symptoms well

ETOH withdrawal under anesthesia has extremely high mortality rate

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48
Q

What induction agent widens thermo-regulation (think anti-shivering) and decreases muscle rigidity?

A

Precedex

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49
Q

What is the standard concentration of Methohexital (Brevital)?

A

1 - 2% or 10 - 20 mg/ml

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50
Q

What is the adult dose of Methohexital (Brevital)?

A

1.5 mg/kg

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51
Q

Why is giving the correct dose of Methohexital (Brevital) so crucial?

A

High doses can treat seizures, whereas low doses can encourage an epileptogenic state and cause myoclonus and hiccups

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52
Q

What is the primary use of Methohexital (Brevital)?

A

For rapid non-painful procedures such as: ECTs (good because it doesn’t depress the seizure), cardioversion and mapping seizure focus

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53
Q

Standard post-op pain dose of morphine?

A

5 - 20 mg

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54
Q

What is the primary concern with intrathecal morphine use?

A

Delayed respiratory depression

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55
Q

Why is Dilaudid preferred over morphine?

A

It has less histamine release

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56
Q

Do you dose fentanyl of IBW or TBW?

A

IBW

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57
Q

What is the dose of fentanyl for the 1st hour of surgery?

A

1 - 5 mcg/kg

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58
Q

What is the infusion rate of fentanyl? When do you DC it?

A

3 - 6 mcg/kg/hr, turn off at least 60 minutes prior to need for patient to breath independently

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59
Q

Primary use for Demerol?

A

To treat shivering

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60
Q

Standard dose of Demerol?

A

12.5 mg IV

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61
Q

What does Demerol structurally mimic?

A

Atropine and LAs

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62
Q

What is the concern with Demerol’s active metabolite?

A

CNS stimulant = seizure risk

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63
Q

What is the dose of Sufentanil?

A

0.5 - 1 mcg/kg

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64
Q

Infusion dose of Sufentanil? When do you DC?

A

0.5 - 1 mcg/kg/hr

DC 30 minutes prior to breathing if the infusion has been running less than 2 hours, DC 45 minutes prior if the infusion has been going greater than 2 hours

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65
Q

Primary advantages of sufentanil?

A

CV stable and better post-op pain control than Remi because it sticks around longer

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66
Q

Standard concentration of sufentanil?

A

50 mcg/ml

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67
Q

What is the loading dose and infusion of Remi?

A

LD: 0.5 - 1 mcg over 1 minute
Infusion: 0.125 - 0.375 mcg/kg/min (turn off 6 min prior to breathing)

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68
Q

What narcotic is primarily metabolized by plasma esterases?

A

Remi

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69
Q

How much can Remi reduce MAC?

A

Up to 70% reduction

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70
Q

Primary uses for Remi?

A

Neuro cases (fast on/off), carotid endarterectomy, eye blocks, TIVA

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71
Q

What intervention must be done with stopping a Remi infusion?

A

Must cover post-op pain with another drug as Remi wears off so quickly

72
Q

In what field/branch of anesthesia are you most likely to use partial agonist/antagonist narcotics?

A

OB

73
Q

What class of drugs can treat pruritis without reversing analgesia?

A

Partial agonist/antagonist narcotics

74
Q

Standard dose to treat respiratory depression with narcan?

A

40 - 80 mcg IV

75
Q

What is the standard concentration of narcan?

A

400 mcg/ml

76
Q

If you want to give 80 mcg of narcan in 2 ml, how would dilute it down from its standard concentration?

A

SC = 400 mcg/ml, there are a few options here, but the easiest way is to keep the numbers simple. Add 9 ml, so you have 400 mcg / 10 ml or 40 mcg / ml, draw up 2 ml and now you have 80 mcg in 2 ml

77
Q

What is the rare but emergency condition associated with narcan?

A

Flash pulmonary edema

78
Q

What are the 5 primary effects of BZDs?

A

Sedation.
Anxiolysis.
Hypnotic.
Anticonvulsant.
Spinal cord – mediated skeletal muscle relaxation

79
Q

List the primary BZDs we use in order of increasing potency?

A

Diazepam -> Midazolam -> Lorazepam

Ativan is x5 more potent than versed, and versed is x5 more potent than valium

80
Q

Why are BZDs discouraged for patients with chronic COPD, OSA and/or obesity?

A

BZDs depress the hypoxic drive to breathe, which is what the 3 listed conditions use to breathe, so a BZD could seriously depress their drive to breathe

81
Q

T/F: BZDs blunt the SNS response to DL and intubation?

A

False

82
Q

Why is PO ativan/valium a good choice for anxiolysis in someone with COPD, OSA or obesity (assuming you MUST give a BZD in this scenario)?

A

The PO route has almost no respiratory depression when used alone

83
Q

What is the standard dose of Flumazenil?

A

0.2 mg IV

84
Q

What is the standard concentration of Flumazenil?

A

0.1 mg/ml or 0.01%

85
Q

What is the max dose of Flumazenil?

A

3 mg total; you can repeat doses of 0.1 mg IV q1m with a max of 1 mg per hour and total max of 3 mg

86
Q

Name the drug: (Anti nausea, anti inflammatory, long acting)

A

Decadron

87
Q

Name the drug: Very safe (watch for QT), difficult to overdose, very effective

A

Zofran

88
Q

Name the drug: Tough to find anymore, Watch QT, can cause sedation/confusion

A

Droperidol

89
Q

Name the drug: … Forward motility, works on dopamine receptor, can cause anxiety, extrapyramidal side effects. Got a bad rap because of flawed studies.

A

Reglan

90
Q

Name the drug: Antihistamine, Histamine receptors are in the chemoreceptor trigger zone

A

Benadryl

91
Q

Name the drug: Very effective for those with motion sickness, multi day treatment, remember education for removal.

A

Scop patch

92
Q

Name the drug: H2 blocker, decreases acid, but can reduce N/V, FDA approved for morning sickness

A

Pepcid

93
Q

Name the drug: Usually a rescue drug, sedation qualities, MUST dilute and make certain IV is working, extravasation can result in loss of limb. IV or IM use only

A

Phenergan

94
Q

Name the drug: Has anti-emetic properties, can be used as a last ditch rescue, can also be used in TIVA, avoiding gas to reduce N/V in high risk patients.

A

Propofol

95
Q

Name the drug: Newer, expensive drug, for use in very high risk patients. A substance P/nk-1 antagonist (also a CTZ trigger). A previously unexplored pathway to prevent N/V

A

Aprepitant

96
Q

What paralytic is essentially just 2 Ach molecules bound together?

A

Sux

97
Q

Sux is antagonized by what? Augmented by what?

A

Antagonized = non-depolarizers
Augmented = acetylcholinesterase

98
Q

What are the primary advantages of Nimbex?

A

No histamine release, dose doesn’t change with illness or age and does not accumulate

99
Q

What is the infusion rate of Nimbex?

A

1 - 2 mcg/kg/min

100
Q

Standard concentration of Nimbex?

A

2 mg / ml or 0.2%

101
Q

What is the paralytic of choice in renal failure?

A

Nimbex - because it is metabolized by plasma cholinesterase’s rather than an organ

102
Q

What paralytic is a monoquateranary aminosteroid?

A

Vecuronium (norcuron)

103
Q

What is the infusion rate of Vec?

A

1 - 2 mcg/kg/min

104
Q

What organ primarily metabolizes Vec?

A

Liver

105
Q

Intubating dose of Vec?

A

0.1 - 0.2 mg/kg

106
Q

Standard concentration of Roc?

A

10 mg/ml or 1%

107
Q

What conditions can prolongate the effect of Roc?

A

Liver failure (moderate) elderly/pregnant (slight)

108
Q

Standard induction dose of Roc? RSI dose?

A

SI = 0.6 mg/kg
RSI = 1.2 mg/kg

109
Q

What Ach-esterase inhibitor is primarily used in peds?

A

Edrophonium

110
Q

What Ach-esterase inhibitor is primarily used at home by the patient?

A

Physostigmine

remember from the Castillo lecture, you can use this to reverse but still keep the analgesic properties of a few drugs

111
Q

List these paralytics in increasing order of onset of action/duration: Neostigmine, Pyridostigmine and Edrophonium

A

Edrophonium (1 - 2 min and lasts 5 - 20) -> Neostigmine (7 - 11 min and lasts 40 - 60) -> Pyridostigmine (16 min and lasts 90)

112
Q

What drug is commonly paired with neostigmine?

A

Glycopyrrolate (Robinul)

113
Q

What anti-cholinergic commonly paired with paralytic reversal agents does not cross the BBB?

A

Glycopyrrolate

114
Q

What are the important contraindications to Sugammadex?

A

Hx of MH, pseudocholinesterase deficiency and can increase plasma K concentration

115
Q

What combination of drugs can offer an alternative to Sux?

A

RSI dose of Roc and reversal with Sugammadex

116
Q

List the shallow/medium block, deep block and intense block reversal dosages of Sugammadex

A

Shallow = 2 mg/kg
Deep = 4 mg/kg
Intense = 16 mg/kg

117
Q

What is the intubating dose of Pancuronium (pavalon)?

A

0.1 mg/kg

118
Q

What is the intubating dose of Mivacurium (Mivacron)?

A

0.15 - 0.2 mg/kg

119
Q

What is the intubating dose of Atracurium (Tracrium)?

A

0.5 - 0.6 mg/kg

120
Q

What is the standard intubating dose of Sux?

A

1 mg/kg

121
Q

What is the initial dose and max dose of flumazenil?

A

ID = 0.2 mg, max is 3 mg

122
Q

What is the induction dose of ketamine?

A

0.5 - 1.5 mg/kg

123
Q

What is the onset and duration of induction dose propofol?

A

Onset = 30 - 60 sec
Duration = 1 - 8 min

124
Q

What is the onset of induction dose etomidate?

A

1 min

125
Q

What is the onset and duration of induction dose ketamine?

A

Onset = 1 min
Duration = 10 - 20 min

126
Q

What is the induction dose of versed?

A

0.1 - 0.2 mg/kg

usually give a dose of fentanyl 50 - 100 mcg after administration of the benzo

127
Q

What is the onset and duration of induction dose versed?

A

Onset = 30 - 60 sec
Duration = 5 - 10 min

128
Q

List the MAC, BG coefficient and vapor pressure of Sevo

A

MAC = 1.8
BG = 0.69
VP = 157

129
Q

List the MAC, BG coefficient and vapor pressure of Des

A

MAC = 6.6
BG = 0.42
VP = 669

130
Q

List the MAC, BG coefficient and vapor pressure of Iso

A

MAC = 1.17
BG = 1.46
VP = 238

131
Q

List the MAC, BG coefficient and vapor pressure of NO

A

MAC = 104
BG = 0.46
VP = 38.770

132
Q

What is the intubating dose, onset and duration of Sux?

A

1 - 1.5 mg/kg
Onset = 30 - 60 sec
Duration = 5 - 10 min

133
Q

What is the intubating dose, onset and duration of Cisatracurium (Nimbex)?

A

Dose = 0.1 mg/kg
Onset = 2 - 3 min
Duration = 40 - 75 min

134
Q

What is the intubating dose, onset and duration of Vecuronium (Norcuron)?

A

Dose = 0.1 mg/kg
Onset = 2 - 3 min
Duration = 45 - 90 min

135
Q

What is the intubating dose, onset and duration of Roc (Zemuron)?

A

Dose = 0.6 mg/kg
Onset = 2 - 3 min
Duration = 35 - 75 min

136
Q

What is the intubating dose, onset and duration of Pancuronium (Pavulon)?

A

Dose = 0.1 mg/kg
Onset = 2 - 3 min
Duration = 60 - 120 min

137
Q

List the 5 paralytics on the clinical reference sheet in increasing order of duration of action

A

Sux -> Roc -> Nimbex -> Vec -> Pancuronium

note, Roc, Nimbex and Vec are of very similar duration

138
Q

What is the 1:1 rule of Neo/Glyco administration?

A

For every 1 mg of Neo, you give 1 ml of Glyco
be careful here, note the units, Glyco is generally 0.2 mg/ml, so for every 1 mg of neo you give 0.2 mg of glyco

139
Q

If you give 3.2 mg of Neo, how much Glyco are you giving?

A

0.64 mg or ~3 ml

In practice, you would likely round that down to 3 mg of Neo and 0.6 mg of glyco/3 ml

140
Q

If you give 0.75 mg of Glyco, how much Neo are you co-administering with it?

A

3.75 mg

141
Q

What is the dose range of Neostigmine?

A

0.04 - 0.07 mg/kg

142
Q

What is the onset/duration of Neostigmine?

A

Onset = 5 - 10 min
Duration = 60 min

143
Q

What is the onset/duration of sugammadex?

A

Onset = 1 - 4 min
Duration = 1.5 - 3 hours

144
Q

What is the initial bolus and maintenance dose of LAST?

A

Bolus = 1.5 ml/kg of 20% lipids over 1 min
Maintenance = 0.25 ml/kg/min

145
Q

What is the max repeat bolus dose of LAST?

A

3 ml/kg

Be careful with the wording here, what is the max repeat BOLUS dose, not total dose

146
Q

What is the max total dose for LAST?

A

8 ml/kg IV

147
Q

What can you increase the maintenance infusion rate for LAST resuscitation if BP continues to decline?

A

Increase from 0.25 to 0.5 ml/kg/min

148
Q

What is the dose, onset and duration of Droperidol?

A

Dose = 0.625 mg
Onset = 1 - 5 min
Duration = 2 - 3 hr

149
Q

What is the dose, onset and duration of Promethazine?

A

Dose = 6.25 - 25 mg
Onset = 1 - 5 min
Duration = 4 - 6 hr

150
Q

What is the dose, onset and duration of Ondansetron?

A

Dose = 4 mg
Onset = 10 min
Duration = 4 - 9 hr

151
Q

What is the dose, onset and duration of Dexamethasone?

A

Dose = 4 mg
Onset = 10 - 30 min
Duration = 2 - 10 hr

152
Q

What is the dose, onset and duration of Scopolamine?

A

Dose = patch
Onset = 2 - 4 hr
Duration = 72 hr

153
Q

What is the anti-emetic dose of Propofol?

A

10 - 15 mg IV followed by 10 mcg/kg/min (drip may not be needed)

154
Q

What is the dosing range for Toradol?

A

15 - 30 mg q6h

155
Q

What is the dosing range for Ibuprofen?

A

200 - 800 mg q6h

156
Q

What is the standard concentration of ephedrine?

A

50 mg/ml

To get to a usable concentration, dilute with 9 cc to get 5 mg/ml, then you can give the standard dose of 5 mg

157
Q

What is the standard concentration of Neosynephrine? Describe how to get it to a usable concentration

A

10 mg/ml

To get to a working concentration, you need to dilute it. Take 1 ml out and dilute with 9 ml of NS. Now you have 0.1 mg/ml or 100 mcg/ml

158
Q

What is the dose and standard concentration of labetalol?

A

Dose = 5mg
Conc = 5 mg/ml

159
Q

What is the dose and standard concentration of esmolol?

A

Dose = 10 mg
Conc = 10 mg/ml

160
Q

What is the dose and standard concentration of hydralazine?

A

Dose = 5 mg
Conc = 20 mg/ml

161
Q

What is the epidural and spinal dose range for Bupivacaine?

A

Epi = 0.0625 - 0.125%
Spinal = 1.25 - 2.5 mg

162
Q

What is the epidural and spinal dose range for Ropivacaine?

A

Epi = 0.08 - 2%
Spinal = 2.5 - 4.5 mg

163
Q

What is the lido w/epi epidural dose?

A

2% in 5 ml bolus

164
Q

What is the epidural and spinal dose range for Fentanyl?

A

Epi = 50 - 100 mcg
Spinal = 10 - 25 mcg

165
Q

What is the spinal dose range for morphine?

A

0.1 - 0.2 mg

166
Q

What VAs can increase HR?

A

Des and Iso

167
Q

How do VAs change Vt, RR and PaCO2?

A

All decrease Vt, increase RR and PaCO2 increases

168
Q

What effects do VAs (other than NO2) have on: cerebral blood flow, ICP, CRMO and seizure likelihood?

A

CBF = increases
ICP = increases
CRMO = decreases
Seizure chance = decrease

Note, N2O does all of the above except CRMO, N2O increases CRMO

169
Q

What volatile increases CRMO?

A

N2O

170
Q

Which VAs most profoundly increase the length of a non-depolarizing muscle blockade?

A

Iso and Des

171
Q

What effects do VAs have on: RBF, GFR and UOP?

A

RBF = decreases
GFR = decreases
UOP = decreases

172
Q

T/F: VAs decrease hepatic blood flow

A

True

173
Q

In general, would VA would be a good choice for a sick ICU patient that is unlikely to be extubated in the OR?

A

Iso

174
Q

What 2 patient populations are at risk to develop issues with propofol?

A

Critically ill adults with head injuries on the infusion greater than 58 hours, and patients on high dose infusions (5 mg/kg/hr)

175
Q

What induction agent would be a poor choice in a patient lacking GABA?

A

Etomidate

176
Q

T/F: Rocuronium is not affected by renal failure

A

True

It is prolonged by liver failure

Semester 4 TxWes (4 decks)

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