Pharm Unit 3 - Aspiration, PONV, Antiarrythmics, locals, fluids Flashcards
1
Q
What is the minimum inhibitory concentration (MIC)?
A
lowest concentration of a given antimicrobial that will inhibit an organisms growth
2
Q
how is antibiotic susceptibility related to MIC
A
MIC increases with reduced susceptibility
3
Q
when does resistance occur
A
when MIC exceeds the tolerable dose
4
Q
What is the post-antibiotic effect?
A
Bacterial killing continues after the serum level drops below the MIC
5
Q
what is time dependent killing
A
-bactericidal activity continues as long as plasma concentration is above the MIC
6
Q
what is an example of time dependent killing
A
beta lactams
7
Q
what is concentration dependent killing
A
efficacy increases as concentration increases
8
Q
examples of concentration dependent killling
A
aminoglycosides and quinolones
9
Q
what type are antibiotics are typically bacteriostatic
A
protein synthesis inhibitors
10
Q
characteristic of a bacteriostatic antibiotic
A
interfere with growth and replication
11
Q
what is empiric therapy
A
treat based on most likely organisms
12
Q
what type of antibiotics are typically bactericidal
A
cell wall acting
13
Q
when are bactericidal abx always used
A
immunosuppressed or severe infection
14
Q
definitive therapy
A
treat based on identified organism
15
Q
preventative therapy
A
prophylaxis based on the most likely organism
16
Q
Persistent suppression of bacterial growth after antibiotic concentration has fallen below the specified MIC is known as
A
post antibiotic effect
17
Q
Antibiotic which may prolong the neuromuscular blocking effects of rocuronium
A
levofloxacin
18
Q
When this agent is combined with ampicillin, it extends the spectrum of activity to be active against more gram negative and anaerobic bacteria
A
sulbactam
19
Q
The mechanism of action of cefotetan is
A
inhibition of crosslinking of peptidoglycan to inhibit bacterial cell wall synthesis
20
Q
Prolonged QT on ECG and cardiac arrhythmia is a possible risk with
A
quinolones
21
Q
antibiotic to avoid in a pregnant patient
A
doxycycline
22
Q
Agent that may be used for decolonization of patients who are nasal carriers of MRSA and MSSA
A
mupirocin
23
Q
vancomycin is associated with all of the following adverse effects except
A
bleeding
24
Q
Select the antiemetic agent that is associated with dry mouth, blurry vision, and may cause cognitive impairment in elderly patients:
A
scopalamine
25
An agent that may be useful for late or delayed nausea and vomiting:
palonosetron
26
Dexamethasone IV injection has been associated with:
perineal burning sensation
27
A patient treated with droperidol in the PACU develops an acute and painful cervical dystonic reaction. Select appropriate therapy to relive the dystonia
diphenhydramine or glycopyrrolate
28
Are beta lactams bactericidal or bacteriostatic?
bactericidal
29
beta lactams MOA
Inhibition of cell wall synthesis: Interference with peptidoglycan crosslinking
30
penicillins spectrum
G+, G-, anaerobes (broad spectrum)
31
Penicillins: Adverse Effects
hypersensitivity reaction, seizure
32
difference between cephalosporins and penicillins
more stable against bacterial beta lactamase
33
1st gen cephalosporin
Cefazolin
34
1st gen cephalosporin coverage
gram positive, some gram negative
35
2nd gen cephalosporin
Cefotetan
36
2nd gen cephalosporin coverage
gram positive, more gram negative
37
3rd gen cephalosporin
Ceftriaxone
38
3rd gen cephalosporin coverage
decreasing gram positive, increasing gram negative
39
4th gen cephalosporin
Cefepime
40
4th gen cephalosporin coverage
G+, G-, pseudomonas
41
5th gen cephalosporin
Ceftaroline
42
5th gen cephalosporin coverage
MRSA
43
cephalosporin adverse effects
allergy, bleeding, disulfiram reaction
44
beta lactamase inhibitors
Clavulanate, Sulbactam
45
beta lactamase inhibitors MOA
inactivate beta lactamase to make other abx more active
46
carbapenems
Meropenem, Ertapenem
Doripenem
47
carbapenems MOA
inhibit cell wall synthesis (resistant to beta lactamases)
48
Carbapanems spectrum
gram positive, gram negative
anaerobes
pseudomonas
49
Carbapenems adverse effects
seizure, renal impairment
50
beta lactamase inhibitors spectrum
G+, G-
anaerobes
51
vancomycin MOA
inhibits synthesis of cell wall precursors
52
Vancomycin spectrum
Gram +: enterococcus
MRSA
C. Diff
53
Vancomycin adverse effects
nephrotoxicity, ototoxicity, red man syndrome
54
aminoglycosides
gentamicin, neomycin, amikacin
55
aminoglycosides MOA
inhibit bacterial protein synthesis (30S subunit)
56
Are aminoglycosides bactericidal or bacteriostatic?
bactericidal
57
Aminoglycosides adverse effects
ototoxicity, nephrotoxicity, prolong neuromuscular blockade
58
macrolides
erythromycin, clarithromycin, azithromycin
59
macrolides MOA
inhibit protein synthesis (50S subunit)
60
macrolides spectrum
G+, pneumococci
61
macrolides adverse effects
GI effects, inhibit CYP 450
62
tetracyclines
Tetracycline, Doxycycline
Minocycline
63
tetracyclines MOA
inhibit protein synthesis (30S subunit)
64
Are tetracyclines bacteriostatic or bactericidal?
bacteriostatic
65
tetracyclines spectrum
Gram (+), mycoplasma, H. pylori, Chlamydia
66
tetracyclines adverse effects
GI altered flora
67
tetracyclines contraindications
pregnancy
68
clindamycin MOA
inhibit protein synthesis (50S subunit)
69
Is clindamycin bacteriostatic or bactericidal?
bactericidal
70
clinda spectrum
most gram pos, most anaerobes
71
Clindamycin adverse effects
C. diff, GI effects
72
oxazolidinones
Linezolid
73
oxazolidinones MOA
prevents formation of ribosome complex
74
oxazolidinones spectrum
G+ (MRSA, VRE, VRSA), vanc resistant enterococci
75
oxazolidinones adverse effects
MAO activity, hematological (anemia, thrombocytopenia), neuropathy
76
DNA synthesis inhibitors
Quinolones
77
quinolones
Ciprofloxacin, Levofloxacin
Ofloxacin
78
quinolones MOA
inhibit topoisomerase
79
quinolones spectrum
Broad (G+ and G-)
80
Quinolones adverse effects
glycemia, QT prolongation
growing cartilage
tendonitics
enhance NMB
81
antimetabolites
sulfonamides
82
sulfonamides MOA
inhibit folate synthesis
83
sulfonamides spectrum
gram positives
84
sulfonamides adverse effects
megaloblastic anemia, leukopenia
granulocytopenia
vasculitis
cross reactivity
85
metronidazole use
add when worried about anaerobes
86
mupirocin use
MRSA nasal colonization
87
polymixins use
bactericidal for abdominal procedures
88
when should the antibiotic be administered?
60 min prior to incision
89
when should vanc be administered
120 min prior to incision
90
what is commonly used when there is a PCN allergy
vancomycin, clindamycin, erythromycin
91
What types of drugs are used for aspiration prevention
H1 blockers
H2 blockers
PPI's
Dopa receptor antagonists
92
H1 blockers MOA
decreased contraction of intestinal smooth muscle
93
H1 blockers uses
sedation, decreased GI motility
antimuscarinic
94
what is the H1 blocker
diphenhydramine
95
H2 blockers MOA
decrease acidity of gastric acid
96
H2 blockers uses
ulcers, GERD
97
H2 blockers common drugs
ranitidine, famotidine, nizatidine, cimetidine
98
PPI MOA
inhibit acid secretion
99
PPI uses
ulcers, GERD
100
PPI common drugs
pantoprazole, omeprazole, lansoprazole
101
dopamine receptor antagonist MOA
increase LES tone & GI motility
102
dopamine receptor antagonist uses
GERD, diabetic gastroparesis
103
dopamine receptor antagonist adverse effects
acute dystonic reaction
104
common dopamine receptor antagonist
metoclopramide
105
5HT3 antagonists MOA
block serotonin both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone
106
5HT3 antagonists uses
emesis due to vagal stimulation
107
5HT3 antagonists adverse effects
QT prolongation
108
5HT3 antagonists contraindications
use w/ drugs that inhibit CYP enzymes
109
common 5HT3 antagonists
ondansetron, granisetron
dolasetron
palonosetron
110
antimuscarinics uses
motion sickness, PONV
111
antimuscarinics adverse effects
dry mouth, blurry vision
cognitive impairment
112
common antimuscarinic for PONV
scopalamine patch
113
D2 receptor antagonist MOA
block D2 receptor in CTZ
114
D2 receptor antagonist adverse effects
acute dystonic reaction, prolonged QT
115
D2 receptor antagonist common drugs
droperidol, haloperidol
perphenazine
promethazine
prochlorperazine
116
Neurokinin receptor antagonists MOA
inhibits substance P
117
Neurokinin receptor antagonist drug
Aprepitant
118
dexamethasone adverse effects
perineal burning, impaired glucose tolerance
119
Class IA antiarrhythmics
Quinidine
Procainamide
Disopyramide
120
Class IA antiarrhythmics MOA
block VG Na+ and VG K+ in myocytes
121
quinidine indications
PVC's
Systained VT/VF
Afib/Aflutter
short QT syndrome
122
quinidine adverse effects
N/V
diarrhea
tinnitus/hearing loss
hypotension
QRS & QT prolongation, torsades
123
quinidine contraindications
prolonged QT
124
Procainamide Indications
sustained VT, Afib in WPW
125
procainamide adverse effects
rash, myalgia, vasculitis, hypotension, bradycardia, QT prolongation, torsades, drug induced lupus
126
Procainamide Contraindications
prolonged QT
127
disopyramide indications
PVC's, VT
Afib
128
dispyramide adverse effects
urinary retention, constipation, glaucoma, QT prolongation, torsades
129
disopyramide contraindications
prolonged QT
130
Class IB Antiarrhythmics
Lidocaine
Mexiletine
131
Class IB Antiarrhythmics MOA
block VG Na+ in myocytes
132
Class IB Antiarrhythmics indications
V tach, V fib
133
Class IB Antiarrhythmics adverse effects
increased potency in ischemic tissue, GI effects
134
lidocaine SE
visaul disturbances
tremor
seizure
drowsiness
hallucination/coma
asystole
hypotension
N/V
135
Mexiletine SE
GI upset
N/V
blurred vision
tremor
headache
ataxia
confusion
136
Class IB Antiarrhythmics contraindications
atrial tachyarrhythmias, HF/liver disease
137
Class IC antiarrhythmics
Flecainide, Propafenone
138
Class IC antiarrhythmics MOA
dramatically prolong phase 0 in myocyte AP (block VG NA+)
139
Class IC antiarrhythmics indications
AFib (w/o CAD), SVT
140
flecainamide adverse effects
dizziness, dyspnea, headache, blurred vision, nausea, HF exacerbation, AV block, VT/VF in pt's with CAD
141
flecainamide contraindications
heart failure
CAD
142
propafenone adverse effects
dizziness, dyspnea, headache, blurred vision, nausea, bradyccardia
bronchospasm
143
propafenone contraindications
heart failure
CAD
asthma
144
Class II antiarrhythmic drugs
beta blockers
145
beta blockers MOA
decreased slope of phase 4 depolarization
prolong depolarization at AV node
146
beta blocker indications
Afib/Aflutter (slow HR down)
SVT's
ventricular arrhythmia prevention
***will not convert back into normal sinus***
147
beta blocker adverse effects
fatigue
hypotension
bronchospasm
mask hypoglycemic symptoms
aggravation of heart failure
148
Class III antiarrhythmics
Amiodarone
149
Class III MOA
K+ blocker
-- prolongs QT interval
150
Class III SE
torsades the pointes
higher proarryhthmia risk
151
Amiodarone MOA
K+ blocker (high)
- prolongs AP duration
- phase 3
Na+ blocker
Ca2+ blocker
beta blocker (slow SA/AV conduction)
152
when does amiodarone work best?
at high heart rates due to use-dependence
153
amiodarone indications
VT/VF
SVT
Afib/Aflutter
154
amiodarone features
lg volume of distribution due to lipophilicity
requires loading dose (10g)
delayed onset
long half life (2 months)
155
amiodarone adverse effects
pulmonary toxicity
liver injury
hypotension
bradycardia
AV block
worsening dysrhthmias
thyroid abnormalities
156
amiodarone contraindications
hypersensitivity (iodine)
cardiogenic shock
bradycardia
AV blocks
157
amiodarone drug interactions
digoxin
warfarin
statins
158
amiodarone metabolism
hepatic by CYP3A4 and 2C8
159
amiodarone inhibits
CYP3A4
CYP2C9
P-glycoprotein
160
Class III drugs that can cause torsades
dofetilide
sotalol
161
dronedarone compared to amiodarone
less efficacy than amiodarone
does not contain iodine
162
dronedarone SE
GI impacts
163
dronedarone indications
atrial flutter
afib
164
Class IV antiarrhythmics
non-DHPR CCB's
verapamil
diltiazem
165
non-DHPR CCB MOA
inhibition of L-type Ca2+ channels (phase 0 in nodal tissue)
slow depolarization in pacemaker cells
166
non-DHPR CCB indications
SVT
Afib/Aflutter
167
non-DHPR CCB adverse effects
hypotension
bradycardia
AV block
decreased SV
168
adenosine adverse effects
dyspnea
bronchospasm
flushing
chest pressure
169
Adenosine indications
SVT
170
digoxin MOA
increases parasympathetic tone via vagus nerve
-- decr sinus node
-- prolongs AV node refractory
inhibits Na/K-ATPase pump
--incr Ca2+
--incr contractility
--incr proarrhythmic potential
171
digoxin indications
atrial fibrillation
aflutter
heart failure w/ reduced EF
172
digoxin CI
afib
aflutter
WPW
173
digoxin adverse effects
narrow therapeutic window
GI upset
halo vision
malaise
bradycardia
AV block
VT/VF
174
when is digoxin used?
on a resting heart rate
-- pt is just sitting not walking around
rate control in combination with BB/CCB
175
Antimuscarinics indications
bradycardia
AV block
176
antimuscarinic side effects
dry mouth
blurry vision
photophobia
tachycardia
177
antimuscarinic drugs
atropine
glyco
178
antimuscarinic MOA
block ACH from binding to muscarinic receptors
alters parasympathetic response
anti-parasympathetic drugs
179
mechanism of action of local anesthetics
Block voltage-gated sodium channels
180
what does Blockage of voltage-gated sodium channels do
blocks generation and conduction of action potentials
181
when do local anesthetics gain access to Na channels
during activated state
182
when is the affinity of LA for Na channels greater
when Na channels are open
183
what does the lipophillic region of LA affect
onset of action
potency
duration
184
increasing lipophilicity
increases potency
slower onset
185
what does ester or amide linkage of LAs affect
duration of action
186
if someone has an allergy to amid local anesthetics, can you safely give an ester?
yes (& vice versa)
187
what does a higher % neutral affect
enhanced absorption
188
how does % neutral affect absoprtion
neutral form penetrates the membrane
189
what do we want the pKa of the LA to be
closest to physiologic pH
190
what is the determining factor for LA toxicity
vascularity
191
Vascularity ranking Highest to lowest
HIGH
IV
tracheal
intercostal
caudal
paracervical
epidural
brachial plexus
subarachnoid/sciatic/femoral
subQ
LOW
192
what does the risk for systemic LA toxicity depend on
lipid solubility
amount of connective tissue in area
pH of tissue
% neutral
is epi added?
193
how does lipophilicity and tissue protein binding affect duration
remains in tissue longer
194
how does epi affect the LA
makes LA more acidic
195
what does bicarb addition to epi + LA
makes it neutral for a faster onset
196
what delays LA redistribution
vasoconstriction
197
why is epi added to local?
prolongs duration of action
reduced peak serum concentration
198
onset of LA: lipid solubility
less lipid soluble = less potent
(typically delays onset)
199
duration of action of LA
potency
lipid solubility - more = slower diffusion = longer DOA
200
what type of axon is more sensitive to LA blcok
myelinated
201
what is the most common feature of LAST
seizures
202
what does a low CC/CNS ratio mean
more cardiotoxic
203
what does a high CC/CNS ratio mean
more CNS toxiv
204
what type of pt is at increased risk for LAST
pregnant elderly
neonate
205
how to treat LAST
lipid emulsion 20% IV, 100 ml bolus over 2-3 min
rebolus 200 mil over 15-20 in
206
Lidocaine maximum dose
4.5 mg/kg
207
Lidocaine + Epi maximum dose
7 mg/kg
208
ropivacaine max dose
2.5 mg/kg
209
bupivacaine max dose
2.5 mg/kg
210
preop causes of volume derangements
bowel preps
bowel obstruction
pancreatitis
blood loss
211
anesthetic causes of volume derangements
anesthetic hypotension
(vasodilation)
sympathetic blockade
212
surgical causes of volume derangements
hemorrhage
coagulopathy
decreased venous return
long operative time
213
when is hypervolemia clincally significant
>10% above basewline
214
hypervolemia SE
incr morbidity
tissue edema
impaired wound healing
pulm edema
decr GI motility
215
what lab value reflects total body water status
serum sodium
216
what content in IV fluid dictates fluid distribution?
Na+
217
what factors influence total body water content
gender
age
nutritional status
disease state
218
TBW and age relationship
less water with increased age
219
neonates TBW
70-80% of body weight is water
220
calculating TBW
50-60% of body weight
221
ICF:ECF
2:1
2/3 ICF and 1/3 ECF
222
ECF
interstitial fluid (3)
plasma (1)
ISF: plasma = 3:1
223
electrolyte content of ECF
Na+
Cl-
224
electrolyte content of ICF
K+
Phosphate
225
what is colloid osmotic pressure
pulls fluid into vessels
226
what maintains fluid components of blood within vessels?
colloid osmotic pressure (oncotic pressure)
227
what changes oncotic pressure
allbumins
proteins
etc
228
what is hydrostatic pressure
pushes fluid out of vessels
229
what is osmolar force
push and pull in and out of vessels
230
what does lactate do in LR?
provides circulating bicarb to provide normal HCO3- levels during acidosis
???????
231
what is the main contributor of osmolarity
sodium
232
Tonicity of Crystalloids
isotonic
233
Distribution of water
ECF and ICF
234
distribution of saline/LR
distributes only to ECF
235
distribution of colloids
distributes only to intravascular space
236
colloid types
albumin
hetastarch
dextrans
236
HES SE
acute kidney
incr moprtaloity
incr need to PRBC transfusion
237
albumin
source of capillary oncotic pressure (80%)
238
types of albumin
hyperoncotic (25%)
5% albumin (isotonic to plasma)
239
pts low in albumin
nutritionally deficient
renal disease
liver disease
240
most potent colloid
25% albumin
241
Hetastarches (HES)
amylopectin and synthetic glycogen
242
HES molecular weight
high MW = slower degradation
243
Dextrans
long chains of glucose (polysaccharides)
244
Dextran unique property
rhological properties
-- moderate plt function
-- antithrombotic
used in vascular sx to prevent post-op stroke
245
typical water loss per day
2.5 L/day
246
causes of increased water loss
fever
sweating
gastric
colon
insensible losses
247
normal Na loss
77 mEq/day
248
normal K loss
40-60 mEq/day
249
normal Cl loss
same as sodium
250
lidocaine pKa
7.6
251
ropivacaine/bupivacaine pKa
8.1
252
how does pKa affect onset
pKa closer to physiologic pH = higher % neutral, faster onset
253
which local anesthetics can cause methemoglobinemia
prilocaine and benzocaine
254
which local anesthetics are more cardiotoxic
bupivacaine
255
which local anesthetics are more CNS toxic
mepivacaine
256
what does extreme lipophilicity promote
continued binding and increased duration of action
257
LA that is extremely lipophilic
bupivacaine
258
what LA property does protein binding affect
duration of action
259
what LA property does pKa affect
onset of action
260
what correlates with toxicity risk
Cmax
time to Cmax
261
what drugs could be used to manage LA systemic toxicity
epinephrine, amiodarone
midazolam
lipid emulsion
262
where will LR/Saline distribute
ECF- 1/4 IV 3/4 IS
263
where will D5W distribute
ECF and ICF proportionally
264
where will Albumin distribute
intravascular space
265
best fluid for maintenance
D5W + 0.225% NaCl
266
best fluid for metabolic acidosis
LR
267
preferred IVF in anesthesia
LR
268
which colloid solutions have a risk for bleeding
6% hetastarch, Dextran 40
269
how to calculate total body water
0.6L/kg
270
N/S SE
hyperchloremic acidosis
reduction of renal perfusion
271
water distribution
across all compartments
vascular compartment
Interstitial space
cell membranes
272
Na+ distribition
capillary membrane
interstitial fluid
pumped out of cell
273
colloids distribution
confined to vascular compartment
does not cross into capillary membrane
274
crystalloids use
mx
replacement of losses
treatments of symptoms
-- fluid or electrolyte deficits
275
colloids uses
add oncotic pressure
volume replacement
rheologic propoerties
276
sensible loses
measurable
277
insensible losses
respriation
fever
evaproration (surgical)
278
adult fluid maintenance
30mL/kg/day
279
minimal losses
0-2 mL/kg
280
moderate losses
2-4 mL/kg
281
severe losses
4-8 mL/kg
282
what fluid dosing is recommended during major invasive surgery?
zero balance approach
- only fluid lost is replaced
