Pharm review Flashcards
MAC % Sevoflurane
1.8
MAC % Desflurane
6.6
MAC % Isoflurane
1.17
MAC % Nitrous Oxide
104
Blood: Gas Sevoflurane
0.69
Blood: Gas Desflurane
0.42
Blood: Gas Isoflurane
1.46
Blood: Gas Nitrous Oxide
0.46
Vapor Pressure Sevoflurane
157
Vapor Pressure Desflurane
669
Vapor Pressure Isoflurane
238
5 things that increase anesthesia Gas requirements
Chronic ETOH
Infant (highest MAC at 6 mo.)
Red hair
Hypernatremia
Hyperthermia
8 things that decrease anesthetic requirements
Acute ETOH
Elderly Patients
Hyponatremia
Hypothermia
Anemia (Hgb < 5 g/dL)
Hypercarbia
Hypoxia
Pregnancy
This Gas can cause airway irritant and can increase HR
Desflurane
These 2 gas can increase HR
iso (increase) and des (N/C or increase)
No change: N2O and sevo
decrease HR: halothane
T/F: all gases decrease BP
F: Nitrous oxide doesn’t have an effect on BP
What 2 gases do not have a decreasing effect on SVR?
N2O and Halothane: no change
What 2 gases do not affect cardiac output?
No change: nitrous oxide and isoflurane
If HR goes up with Des then there is N/C with CO, but if HR isn’t effected then CO goes down
T/F: all VA decrease tidal volume
T
T/F: all VA increase respiratory rate
T
T/F: All VA decrease PaCO2 at rest and challenge
F: all increase
T/F: all VA decrease cerebral blood flow
F: all increase CBF and ICP
T/F: all VA increase cerebral metabolic rate
F: all VA except N2O decrease cerebral metabolic rate
Nitrous oxide increases cerebral metabolic rate
T/F: all VA decrease risk of seizures
T
T/F: VA do not augment nondepolarizing blockade
F
T/F: all VA decrease renal blood flow, GFR and UO
True
Induction dose of Propofol (Diprivan)
1.5-2.5 mg/kg IV
* 2 mg/kg
Sedation maintenance rate for Propofol
25-100 mcg/kg/min
TIVA maintenance rate for Propofol
100-300 mcg/kg/min
This induction agent dose rarely needs to be changed with renal or liver disease. May decrease dose in elderly pts.
Propofol
onset of Propofol
30-60 secs
Duration of Propofol
1-8 mins
What induction agent causes bronchodilation and blunts SNS response to laryngoscopy
Propofol
MOA of Propofol
GABA
MOA of Etomidate
GABA modulator does not mimic has to have GABA present
This induction agents has a Carboxylated imidazole like versed
Etomidate
this induction agent is used when cardiovascular stability is necessary
Etomidate
this induction agent can induce seizures
etomidate
Induction Dose for Etomidate
0.3 mg/kg
onset of etomidate
1 min
This induction drug can cause adrenocortical suppression (cortisol) up to 4-8 hrs
etomidate
This induction drug has the highest % of PONV
Etomidate
This induction agent is not a hypnotic but causes dissociative anesthesia by depressing the neuronal function of the cortex and the thalamus, but stimulates the limbic system
It also activates opioid receptors and subcortical neurons in the spinal tract –> analgesic effects
Inhibits activation of NMDA receptors by glutamate and decreases the presynaptic release of glutamate
Ketamine
onset of Ketamine IV and IM
1 min IV
5 mins IM
duration of ketamine
10-20 mins
maintenance dose of ketamine IV and IM
0.2-0.5 mg/kg IV
4-8 mg/kg IM
Induction dose of Ketamine
0.5-1.5* mg/kg
EPS symtoms caused by ketamine will last how long after?
1 hr
metabolism for ketamine
hepatic
clearance: renal
Contraindications for Ketamine
No MAOIS –> increases epi
This Induction agent maintains pharyngeal and laryngeal reflexes, but secretions can cause Coughing and Laryngospasm
dt dissociation airway is not considered protected
ketamine
this induction agent has an intense bronchodilator effect dt B2 stimulation and can treat status asthmaticus
ketamine
Induction dose for midazolam
0.1-0.2 mg/kg
- may proceed dose with fentanyl 50-100 mcg
This medication is used to tx increased salivary sections from ketamine use
Robinul (anti-salagog)
Induction agent is a Potent cerebral vasodilator; ↑ CBF by 60%
ketamine
This induction agent ↑SVR – PVR, ↑HR, ↑CO, ↑MVO2, ↑SNS outflow, ↑Epi,Norepi – inhibit
reuptake
ketamine
Loading dose of dexmedetomidine
1 mcg/kg over 10 mins, if given too fast then transient hypertension will occur initially
the infusion rate of precedex
0.2-0.7 mcg/kg/hr
Minimal respiratory depressant effects (respiratory sparing) the least of all the induction drugs.
Sleep like depression.
Anti-salagog (Dries them up).
Watch for obstruction (sleep apnea) still not protected airway – especially in obese.
ABG normal, no big change in TV, RR
dexmedetomidine
Morphine intraop dose
1-10 mg
Morphine post-op dose
5-20 mg
Onset of morphine IV
10-20 min
duration of morphine IV
4-5 hrs
this opioid has a prolonged half-life in elderly, liver failure, and renal failure pts
morphine
____ has a potential for delayed respiratory depression up to 24 hr after intrathecal administration
morphine
Dt it being hydrophilic, stays in CSF longer —> late respiratory depression
fentanyl intra-op dose
1-3 mcg/kg
onset of fentanyl
30-60 secs
duration of fentanyl
1-1.5 hrs
sufentanil intraop dose
0.3-1 mcg/kg
onset of sufentanil
30-60 secs
duration of sufentanil
1-1.5 hrs
infusion rate of sufentanil
0.5-1 mcg/kg/hr
remifentanil intraop dose
0.5-1 mcg/kg over a min
infusion rate of remifentanil
0.125-0.375 mcg/kg/min
onset of remifentanil
30-60 secs
duration of remifentanil
6-8 mins
Meperidine (Demerol) postop dose for shivering
12.5 mg
onset of meperidine
5-15 mins
duration of meperidine
2-4 hrs
hydromorphone intraop dose
1-4 mg
postop dose of Hydromorphone
1.5-4 mg
onset of Hydromorphone
5-15 mins
duration of hydromorphone
2-4 hrs
Naloxone (Narcan) dose
40-80 mcg
** supplied: 400 mcg/mL (must dilute)
onset of naloxone
1-5 mins
duration of naloxone
30 mins
this drug is 7x more potent than morphine and has less histamine release
hydromorphone
is fentanyl dosed on IBW or TBW
IBW
Infusion rate of fentanyl
- off 60 mins before breathing
3-6 mcg/kg/hr
another name for fentanyl
sublimaze
this drug has affinity for mu, kappa, and delta opioid receptors
Meperidine
this drug is structurally similar to atropine and LA
meperidine
this drugs active metabolite can cause CNS stimulation –> seizures
meperidine
This drug is contraindicated with MAOIs and blocks the reuptake of serotonin
Meperidine
This opioid is a highly selective mu-opioid receptor agonist
sufentanil
0.5-1mcg/kg/hour (<2hrs = 30 min before breathing;
>2hrs = 45 min before breathing)
sufentanil
This opioid is CV stable
sufentanil
another name for remifentanil
ultiva
remifentanil infusion should be turned off for how many mins before breathing
6 mins
this opioid has quick respiratory depression/bradycarida and decreases MAC requirements by 70%
Remifentanil
This opioid is commonly used for neuro, carotid endarterectomy, eye blocks, and TIVA
Remifentanil
Nalbuphine other name
*opioid agonist/antagonist
Nubaine
Nalbuphine (Nubaine) dose
10 mg
** 10 mg = 10 mg morphine
This opioid agonist/antagonist is great for cardiac catheterization
Nalbuphine (Nubaine): CV- no increase in BP, PA BP, HR, or atrial filling pressures
Other name for Buprenorphine
Buprenex
dose of Buprenorphine (Buprenex)
0.3 mg IM
0.3 mg = 10 mg morphine
This agonist-antagonist is commonly used to tx opioid use disorder, chronic pain, and cx pain
used more frequently than methadone dt less respiratory depression, constipation, immune suppression, and no accumulation in renal patients
Buprenorphine (Buprenex)
Another name for Butorphanol
Stadol
Dose for Butorphanol (Stadol)
2-3 mg IM = 10 mg Morphine
** causes respiratory depression & increases BP, PA BP, & C0
this drug you can see cardiac stimulation r/t abrupt reversal of analgesia and has a potential for flash pulmonary edema
Naloxone (Narcan)
Dose for Diazepam (Valium) IV and PO
0.1 mg/kg IV
0.2 mg/kg PO
Onset for Diazepam
1-5 min
duration for diazepam
2-6 hrs
Dose for Lorazepam (ativan)
0.04 mg/kg
onset for Lorazepam
1-5 mins
duration of lorazepam
6-10 hrs
dose for midazolam (versed)
1-5 mg or (0.05 mg/kg)
onset for midazolam
1-5 mins
duration of versed
15-80 mins
Flumazenil other name
Romazicon
dose of Flumazenil (romazicon)
0.2 mg (repeat 0.1 q1 min)
May repeat with 0.1 mg iv every 1 minute to a total of 1 mg in the first hour and 3 mg maximum dose.
Onset of Flumazenil (romazicon)
1-5 mins
Duration of action: Flumazenil
30-60 mins
- shorter half-life than the drugs it reverses
Max of Flumazenil (Romazicon)
3 mg
Rank these benzos from most to least potent: Diazepam, Lorazepam, Midazolam
Lorazepam > Midazolam > Diazepam
Lorazepam is 5x more potent than Midazolam and Midazolam is 5x more potent that Diazepam
T/F: Benzos cause a significant drop in BP
F: benzos may cause a small drop in BP with sedation, but is minimal
What are the respiratory effects of benzos?
dose-dependent respiratory depression
with high doses —> depresses airway reflexes and ability to swallow
Do benzos affect pt’s hypoxic drive to breathe?
Yes
Normally breathing is driven of CO2, however, some patients now use Oxygen/hypoxia to trigger breathing.
Ex.
1. Chronic COPD
2. Sleep Apnea
3. Morbid Obesity.
This drug will depress their drive to breathe.
Can a small dose of midazolam cause apnea in a healthy person?
Yes, ANY DOSE, ANY PATIENT, CAN CAUSE APNEA IWTH MIDAZOLAM
T/F: Benzos blunt SNS response to intubation
F: benzos do not blunt the SNS response to intubation
T/F: PO diazepam and Lorazepam has almost no respiratory depression when used alone
True
Droperidol’s dose
Reminder: Anti-dopaminergics (Butyrophenones)
< 0.625
** don’t go any higher dt black box warning - torsades de pointes and sudden death at higher doses
onset of droperidol
1-5 mins
Duration of droperidol
2-3 hrs
Promethazine (Phenergan) dose
Reminder: Anti-dopaminergics (phenothiazines) - typically used as a rescue drug
6.25 - 25 mg
this drug has this black box warning
“Black box: tissue damage; respiratory arrest < 2 y/0”
also cause Sedation, hypotension, EPS
Phenergan
The onset of promethazine (Phenergan)
1-5 mins
Duration of promethazine (Phenergan)
4-6 hrs
Ondansetron (Zofran) dose
4 mg
Ondansetron (Zofran) onset
10 mins
Ondansetron (Zofran) duration
4-9 hrs
Dexamethasone (Decadron) dose
4 mg
Dexamethasone (Decadron) onset
10-30 mins
Dexamethasone (Decadron) duration
2-10 hrs
Metoclopramide (Reglan) dose
10-20 mg
Metoclopramide (Reglan) onset
10 mins
Metoclopramide (Reglan) duration
2hrs
SE of Metocolpramide
Restlessness, EPS
Scopolamine patch onset
2-4 hrs
scopolamine patch duration
72 hrs
this drug causes: forward motility, works on dopamine receptor, can cause anxiety, extrapyramidal side
effects. Got a bad rap because of flawed studies.
Metoclopramide (Reglan)
This drug is a H2 blocker, decreases acid, but can reduce N/V, FDA approved for morning sickness
Famotidine (Pepcid)
Famotidine (Pepcid) dose
20 mg
Famotidine (Pepcid) onset
< 30 mins
Famotidine (Pepcid) duration
10-12 hrs
Diphenhydramine (Benadryl) dose
H1 antagonist
25-50 mg
elderly 12.5 mg
Diphenhydramine (Benadryl) onset
< 30 mins
Diphenhydramine (Benadryl) duration
4-8 hrs
Propofol antiemetic dose
10-15 mg IV, followed by 10 mcg/kg/min
Emend (Aprepitant) dose
Reminder: Antagonize Substance P in the emetic center
give 2-3 hrs prior to induction
40mg or 125 mg
Succinylcholine (Anectine) dose
1-1.5 mg/kg
Succinylcholine (Anectine) onset
30-60 seconds
Succinylcholine (Anectine) duration
5-10 mins
Cisatricurium (Nimbex) dose
0.1 mg/kg
Cisatricurium (Nimbex) onset
2-3 mins
Cisatricurium (Nimbex) duration
40-75 mins
What intermediate-acting neuromuscular blocking agent is the safest to use in renal patients
Nimbex dt Hoffman elimination
What two NMBA drugs are intermediate acting
Roc and Vec
Vecuronium (Norcuron) dose
0.1 mg/kg
Vecuronium (Norcuron) onset
2-3 mins
Vecuronium (Norcuron) duration
45-90 mins
Rocuronium (Zemuron) dose
0.6 mg/kg or 1.2 mg/kg
Rocuronium (Zemuron) duration
35-75
Rocuronium (Zemuron) onset
2-3 mins (0.6 mg/kg)
1.5 mins (1.2 mg/kg)
Pancuronium (Pavulon) dose
0.1 mg/kg
Pancuronium (Pavulon) onset
2-3 mins
Pancuronium (Pavulon) duration
60-120
This paralytic is an isomer of atracurium and 4x more potent
nimbex
If you give sux firs to intubate the patient then switch to vecuronium. What is the dose for vec?
0.05 mg/kg
Can vecruonium (norcuron) accumulate in renal patients
yes
If you give sux to intubate then switch to rocuronim (zemuron), what dose would you use for Roc?
0.3 mg/kg
Is Rocuronium affected by renal failure and/or liver failure
Not affected by renal failure, but moderate prolongation in liver failure
** no active metabolites, excreted unchanged by the kidneys and excreted unchanged in bile
This paralytic is slightly prolonged in the elderly and pregnant woman
Rocuronim dt a reduction in plasma cholinesterase activity.
Edrophonium (Tensilon) and Neostigmine (Prostigmin) are in this drug class
anticholinesterase inhibitors
Edrophonium (Tensilon) is also referred to as fast eddy
This drug is commonly used in what population and is frequently paired with what anticholinergic?
peds and paired with atropine
Edrophonium dose
max: 1 mg/kg range
will not work with deep block (0/4 twitches)
Edrophonium onset
1-2 mins
Edrophonium duration
5-15 mins
Neostigmine (Prostigmin®) dose
40-70 mcg/kg
or
0.04-0.07 mg/kg
Neostigmine (Prostigmin) onset
5-10 mins
Neostigmine (Prostigmin) duration
60 mins
Atropine dose (paired with Edrophonium)
7-10 mcg/kg
Glycopyrrolate dose when paired with Neostigmine
7 to 15 µg/kg (1 mg maximum)
** glycopyrrolate 0.2 mg per mg of Neostigmine
Sugammadex is contraindicated in what population
dialysis patients
**eliminated in urine
Sugammadex dose in a moderate block (2/4 twitches)
2mg/kg
Sugammadex dose in a deep block (reached 1-2 post-tetanic counts, no twitch responses to TOF)
4 mg/kg
Sugammadex dose in an extreme block (0/4 twitches with TOF and no PTS)
8-16* mg/kg
side effect of neostigmine
bradycardia
that is why it is paired with glycopyrrolate (Robinul)
Glycopyrrolate (Robinul) onset
2-3 mins
Glycopyrrolate (Robinul) duration
2 hrs
This Anticholinergic causes tachycardia, bronchodilation, and antisialagogue (but less tachycardia than atropine)
Robinul
- neostigmine can cause severe bradycardia –> asystole, which is why it is paired with Robinul to counteract each other
Dose sugammadex inhibit acetylcholinesterase?
No
MOA: MOA: intermolecular (van der Walls) forces, thermodynamic (hydrogen) bonds, and hydrophobic interactions* → very tight reversal by encapsulation
*Rocuronium > Vecuronium»_space; Pancuronium
**Binds to ‘free drug” in plasma
Dantrolene dose
2.5 mg/kg IV; repeat q5-10 mins
Dantrolene max
10 mg/kg
LAST intalipid 20% bolus dose
1.5 mL/kg over 1 min
how often can you repeat the lipid bolus for LAST
q 3-5 mins up to 3 ml/kg until circulation is restored
Once circulation is restored after intralipid bolus, what infuse rate do you start intralipids at?
0.25 ml/kg/min
If a patient goes into laryngospasm and it doesn’t break with PPV and Larson’s maneuver. What dose of succinylcholine can you give?
10-20 mg IV
dose of ephedrine
5 mg
on hand: 50mg/mL (add 9 cc Ns)
Neosynephrine works on what receptor
alpha
dose of neosynephrine
100 mcg
on hand: 10 mg/mL
