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Semester 2 TxWes > Pharm Unit 4 > Flashcards

Pharm Unit 4 Flashcards

1
Q

List the intermediate acting NMBDs in order of fastest to longest time to maximum block

A

Roc (1.7 min) < Vec (2.4 min) < Atracurium (3.2 min) < Cisatracurium (5.2 min)

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2
Q

Which paralytics do not have an intubating dose of 0.1 mg/kg?

A

D-tubocurarine/Rocuronium (both are 0.6 mg/kg), atracurium (0.5 mg/kg) and mivacurium (0.15 mg/kg)

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3
Q

What are 3 synonymous terms for NMBD reversal agents?

A

AChE inhibitors, cholinergic agents and competitive antagonists

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4
Q

How do our NMBD reversal drugs work?

A

By inhibiting AChE there is more ACh around to bind to alpha subunits

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5
Q

What is the max ceiling range for Neostigmine and edrophonium?

A

Neo = 40 - 70 mcg/kg
Edro = 1 mg/kg

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6
Q

What 5 factors affect NM blockade reversal?

A

Depth of the NM Block
AChE Inhibitor choice
Dose administered
Rate of plasma clearance of NMBD
Anesthesia agent choice and depth (affects residual blockade)

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7
Q

Per the table from lecture one, what is the only paralytic that does not achieve 100% block?

A

d-tubocurarine

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8
Q

What is the dose of neostigmine, onset and duration?

A

0.04 - 0.07 mg/kg (or 40 - 70 mcg/kg)
Onset = 5 - 10 minutes
Duration = 60 min

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9
Q

What is neostigmine paired with and at what dose?

A

Glycopyrrolate at 0.2 mg per mg of Neostigmine

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10
Q

What is the dose, onset and duration of sugammadex?

A

2-16 mg/kg
Onset = 1 - 4 min
Duration = 1.5 - 3 hours

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11
Q

What is the dose, onset and duration of edrophonium?

A

0.5 - 1 mg/kg
Onset = 1 - 2 minutes
Duration = 5 - 15 minutes

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12
Q

What is another name for TOF testing?

A

Acceleromyography

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13
Q

What is the duration of clinical response of short, intermediate and long acting paralytics?

A

Short = ~15 minutes
Intermediate = 35 - 45 minutes
Long = ~80 - 85 minutes

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14
Q

What is the max dose of neostigmine?

A

5 mg

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15
Q

Describe the clearance of Neostigmine

A

50% renal, 30-50% is cleared by the liver if there is no renal function, making the kidneys the primary organ that gets rid of neostigmine

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16
Q

What are the s/e of Neostigmine?

A

Increased Nicotinic/Muscarinic activity
CV: Bradycardia, dysrhythmias, asystole, ↓SVR
Pulmonary: Bronchoconstriction, increased airway resistance, increased salivation
GI: Hyperperistalsis, enhanced gastric fluid secretion, PONV
Eyes: Miosis

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17
Q

What are our anti-cholinergic agents we pair with reversal agents?

A

Atropine and glycopyrrolate

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18
Q

What is the dose of atropine and glycopyrrolate?

A

Atropine = 7 - 10 mcg/kg (watch for tachycardia)
Glycopyrrolate = 7 - 15 mcg/kg (1 mg max)

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19
Q

What anti-cholinergic would you give alongside edrophonium?

A

Atropine (both drugs have a short duration)

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20
Q

What anti-cholinergic would you give alongside neostigmine or pyridostigmine?

A

Glycopyrrolate (both drugs have a longer duration)

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21
Q

What anti-cholinergic would you give in a patient with heart disease?

A

Glycopyrrolate slowly over 2 - 5 minutes

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22
Q

What is the rule of thumb when giving glycopyrrolate and neostigmine together?

A

You need the ml’s of both to match, or have neostigmine be higher

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23
Q

What reversal drugs work on Mivacurium, Gantacurium and Rocuronium?

A

Miva = Purified human plasma cholinesterase
Gan = Cystiene
Roc = Sugammadex

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24
Q

What is the trade name of sugammadex?

A

Bridion

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25
Q

What are the generic names of glycopyrrolate and neostigmine?

A

Glyco = Robinul
Neo = Prostigmin

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26
Q

What are some chemical characteristics of sugammadex?

A

Y-cyclodextrin, made up of dextrose units from starch and highly water soluble

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27
Q

How does sugammadex work?

A

Taking advantage of intermolecular/thermodynamic bonds/forces and hydrophobic interactions, it encapsulates your paralytic drugs

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28
Q

List these drugs in increasing ability of sugammadex to nullify: Vecuronium, Pancuronium and Rocuronium

A

Pancuronium < Vecuronium < Rocuronium

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29
Q

What is the primary elimination method of sugammadex?

A

In the urine, 70% in 6 hours, 90% in 24 hours. Give with care in renal failure

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30
Q

What is the generic classification of sugammadex?

A

Selective relaxant-binding agent

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31
Q

What is the moderate block, deep block and extreme block dose of sugammadex?

A

Mod = 2 mg/kg
Deep = 4 mg/kg
Extreme = 8 - 16 mg/kg

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32
Q

S/e of sugammadex?

A

(all are dose related)
N/V, pruritus, Urticaria, anaphylaxis, bradycardia or just doesn’t work

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33
Q

If a dose of sugammadex is given, and you have already given a dose of Roc but need to give another dose of Roc (can’t use a different drug in this scenario) how long would it take for a 0.6 mg/kg dose vs a 1.2 mg/kg dose to kick in?

A

0.6 = 4 hours (this timeframe would still be the case if you gave 0.1mg/kg of Vec)
1.2 = 5 minutes

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34
Q

If you need to redose a paralytic after giving sugammadex, what paralytics could you give?

A

Sugammadex is used to reverse aminosteroids, so use benzylisoquinilones; atracurium, cisatracurium or mivacurium

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35
Q

What are some cautions to giving sugammadex?

A

Pt is on oral contraceptives (can bind to progesterone, contraceptive won’t work for 7 days), pt is on toremifene (displaces NMBD from sugammadex), if pt is bleeding (elevates coagulation labs) and recurarization at lower than recommended doses

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36
Q

What is recurarization?

A

Reparalyzation, s/sx = drop in O2 sats, unresponsive patient, appears “floppy” or uncoordinated and ineffective abdominal/intercostal activity

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37
Q

If you suspect recurarization, what are you treatment goals?

A

Re-sedate the patient and give additional reversal agents in divided doses (such as neostigmine of 0.05 mg/kg IV)

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38
Q

What was the first local anesthetic?

A

Cocaine

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39
Q

1st synthetic ester and amide LA?

A

Synthetic ester = Procaine
Synthetic amide = Lidocaine

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39
Q

What are are some non-anesthesia related uses for LA drugs?

A

(think lidocaine), treat dysrhythmias (Sodium channel blocker), treat pain

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40
Q

What is the IV drip/dose of lidocaine?

A

Initial bolus: 1-2 mg /kg IV
Drip: 1-2 mg/kg/hour for 12 - 72 hours

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41
Q

List the plasma lidocaine concentration and their side effects (in mcg/ml)

A

1-5 = Analgesia
5-10 = Circum-oral numbness, tinnitus, skeletal muscle twitching, hypotension, myocardial depression
10-15 = seizures, unconsciousness
15-25 = apnea, coma
25 < cardiovascular depression

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42
Q

Describe the basic structure of an LA

A

A lipophilic portion connected by a hydrocarbon chain to the hydrophilic portion, bond between 1 (lipopholic) and 2 (intermediate chain) classifies it as an ester or amide

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43
Q

With the intermediate chain, what differentiates an ester vs amide?

A

Ester = COOR in the chain
Amide = NHCO in the chain
In general; the bond between the lipophilic portion and the intermediate chain creates the differentiation of LAs

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44
Q

What are most LAs classified as in terms of pH?

A

Weak bases

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45
Q

What are the ester LAs? Amide?

A

Ester = Procaine, chloroprocaine, tetracaine
Amides = lidocaine, prilocaine, mepivacaine, bupivacaine, levobupivacaine, ropivacaine

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46
Q

List the esters in terms of potency, onset, duration and max dose

A

Procaine (1), slow, 45-60 duration and max dose of 500 mg
Chloroprocaine (4), rapid, 30-45 duration and max dose of 600 mg
Tetracaine (16), slow, 60-180 duration and max dose of 100 mg

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47
Q

What is the trick to remember what is an amide vs an ester?

A

Amides have 2 “I’s” in the name
Esters have 1 “I”

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48
Q

What is the only rapid onset amide?

A

Lidocaine

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49
Q

What is the potency, onset, duration and max single dose of lidocaine

A

1, rapid, 60-120 minutes and 300 mg

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50
Q

What is the potency, onset, duration and max single dose of Bupivacaine

A

4, slow, 240-480 minutes and 175 mg

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51
Q

What LA has the highest fraction non-ionized?

A

Mepivacaine

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52
Q

What LA has the highest lipid solubility?

A

Tetracaine

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53
Q

What LA has the highest VD?

A

Prilocaine @ 191

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54
Q

What LA has the highest clearance?

A

Mepivacaine, 9.78

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55
Q

What LAs are liposomes?

A

Lidocaine, tetracaine and buipivacaine

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56
Q

Basic MOA of LAs?

A

Bind to voltage gated Na channels and block/inhibit Na passage in nerve membranes -> slows depolarization and APs can’t reach threshold

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57
Q

What are 3 factors affecting blockade with an LA?

A

Lipid solubility or non/ionized form, repetitively simulated nerve, diameter of the nerve

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58
Q

What is MEC?

A

Minimum effective concentration of an LA, 1 MEC = 2-3 nodes of Ranvier blocked (about 1 cm blocked)

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59
Q

What fibers block fastest? Slowest?

A

Fast = Preganglionic B fibers
Slow = C fibers

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60
Q

Which pKa’s have the most rapid onset?

A

Those closest to physiologic pH

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61
Q

What factors influence absorption of an LA?

A

Site of injection, dosage, use of epinephrine and pharmacologic characteristics of the drug

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62
Q

List the routes of LA administration from least amount uptaken in the blood to most

A

SubQ < Sciatic < Brachial < Epidural < Paracervical < Caudal < Tracheal < IV

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63
Q

What is the primary determinant of LA potency?

A

Solubility

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64
Q

What are the 2 primary factors that affect clearance of LAs?

A

CO and protein binding

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65
Q

List these LAs from least to most protein bound (Bupivacaine, mepivacaine and lidocaine)

A

Lidocaine < mepivacaine < bupivacaine (this is the MOST protein bound)

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66
Q

What metabolizes Amides?

A

Microsomal enzymes in the liver

67
Q

What amide metabolizes fastest? Slowest?

A

Fast = prilocaine
Slow = Bupivacaine, ropivacaine and etidocaine

68
Q

What metabolizes esters? General concern?

A

Hydrolysis by plasma cholinesterase, they have an a metabolite with an allergy concern: PABA

69
Q

In general, what metabolize faster, amides or esters?

A

Esters

70
Q

What LAs are subject to a first pass pulmonary effect?

A

Lidocaine, Bupivacaine and prilocaine

71
Q

What LA class has pregnancy concerns?

A

Amides (they cross the placental barrier more than esters). Another concern is ion trapping of the fetus

72
Q

List the amides from least to most protein bound

A

Prilocaine (55%) Lidocaine (70%) and Bupivacaine (95%)

73
Q

Lidocaine metabolite?

A

Xylidide

74
Q

What is the max dose of lidocaine with and without epi

A

Without = 300mg
With = 500 mg

75
Q

What is the primary concern with Prilocaine?

A

Can convert Hgb into MetHgb

76
Q

Tx for MetHgb related to prilocaine?

A

Methylene blue 1-2 mg/kg IV over 5 min, max dose of 7-8 mg/kg

77
Q

What LAs prefer to bind to a1-Acid glycoprotein?

A

Bupivicaine, Ropivacine

78
Q

What esters are primarily broken down by hydrolysis? list them from least to most broken down by hydrolysis

A

Tetracaine < procaine < chloroprocaine

79
Q

What LA is a weak acid?

A

Benzocaine

80
Q

How does alkalization affect LAs?

A

Faster onset, enhances depth and increase the spread

81
Q

With a pH of 7.4, random drug is a weak acid with a pKa of 8.5, is it more ionized or non-ionized?

A

Non-ionized

82
Q

With a pH of 7.4 random drug is a weak base with a pKa of 9.1, is it more ionized or non-ionized?

A

More ionized

83
Q

What adjuvants mixed with LAs can increase their duration?

A

Dexmedetomidine IV, magnesium, chlonidine/ketamine and dexamethasone

84
Q

Why do we use constrictors with LAs?

A

The duration of action of a LA is proportional to the time the drug is in contact with nerve fibers. So by using a constrictor, we can increase the length of the LA

85
Q

What is the concentration of 1:200,000? 1:500,000?

A

(divide 1 mil/x) 5 mcg/ml and 2 mcg/ml

86
Q

What is the concentration of 1:10,000 and 1:1,000

A

10k = 100 mcg/ml or 0.1 mg/ml
1k = 1000 mcg/ml or 1 mg/ml

87
Q

What is 1% concentration? 2? 4?

A

1 = 10 mg/ml
2 = 20 mg/ml
4 = 40 mg/ml

88
Q

What is the 0.25% concentration? 0.5?

A

0.25 = 2.5 mg/ml
0.5 = 5 mg/ml

89
Q

Clinical Scenario: Your surgeon injected 20 mLs of Bupivacaine 0.25% with 1:200,000 of Epi.

What are the total mgs for Bupivacaine and the total mcgs for Epinephrine?

A

B: 0.25% = 2.5 mg/ml, 2.5 mg x 20 ml = 50 mg total

E: 1:200,000 = 5 mcg/ml x 20 = 100 mcg total

90
Q

What is the normal and epi dose of lidocaine and bupivacaine?

A

L: 300 mg alone, 500 w/epi
B: 175 mg alone, 225 w/epi

91
Q

Primary use for cocaine?

A

Nasal surgery

92
Q

What is EMLA?

A

Eutectic mixture of LAs

93
Q

What is the dose and onset of EMLA cream?

A

2.5% lido and 2.5% prilocaine, 1-2 gms per 10 cm sq of area, 45 minute onset

94
Q

Cautions to use of EMLA cream?

A

MetHgb, skin wounds or amide allergies

95
Q

When is subQ LA w/epi contraindicated?

A

Tissues with end arteries (digits, ears, nose, penis)

96
Q

What is the general trend of numbing with an LA?

A

Proximal body parts numb first followed by distal, proximal recovers first followed by distal (core numbs first and recovers first)

97
Q

What LAs is generally used in a Bier block?

A

Lidocaine is most commonly used (mepivacaine is the “better” choice per slide 66)

98
Q

Describe the steps of a Bier block

A

Iv start -> exsanguination -> double cuff -> LA injection -> IV DC

99
Q

With neuraxial anesthesia, list the systems of sensory, motor and SNS in correct sequence of blockade (first to blockade to last)

A

SNS then sensory then motor

100
Q

With spinal anesthesia (direct injection) describe the level of sensory effect, SNS and motor effects via level of the spinal cord

A

Sensory = same level of denervation
SNS = 2 spinal segments cephalad (above) of sensory
Motor = 2 spinal segments below

101
Q

What do we base the dosage of subarachnoid block on?

A

Height of patient (volume of subarachnoid space)
Segmental level of anesthesia desired
Duration of anesthesia desired

102
Q

What is most important when giving a drug via the subarachnoid space: dose, concentration or volume of drug?

A

dose

103
Q

Most common drug used in an epidural?

A

Lidocaine

104
Q

Describe the differential zone of SNS, sensory and motor blockade with an epidural

A

No difference

105
Q

Describe tumescent liposuction

A

SubQ infiltration of large volumes (5L) of dilute lidocaine (0.05% to 0.1%) with 1:100,000 (10 mcg/ml) of epi

106
Q

How would you dose neuraxial anesthesia in terms of volume?

A

1 ml starting at 5 foot tall, then 0.1 ml per inch above 5 feet

107
Q

PABA is a common source of allergic reactions with LAs, what is the other mentioned in lecture?

A

Methylparaben

108
Q

Are allergies more common in esters or amides? Why?

A

Esters because they have PABA

109
Q

LAST = LA systemic toxicity, what are 2 common reasons this can occur?

A

Entrance into the systemic circulation from inactive tissue redistribution and clearance metabolism or accidental direct IV injection

110
Q

What does the magnitude of systemic absorption depend on with LAs?

A

Dose, Vascularity of site, epinephrine use and physiochemical properties

111
Q

What lab value in conjunction with suspected toxic levels of lidocaine can promote seizures?

A

Hyperkalemia

112
Q

What changes EKG changes are consistent with high plasma concentrations of lidocaine?

A

Slowed conduction: prolonged PR, QRS widening

113
Q

IV bupivacaine is far more cardiotoxic than lidocaine, with toxic plasma levels, what EKG changes would you expect to see?

A

Precipitous hypotension, AV block, Cardiac dysrhythmias: SVTs, ST changes, PVCs, widening of QRS, V-tach

114
Q

What can predispose you to LA CV toxicity?

A

Pregnant, hypoxic/acidotic/hyercarbic, on BBS/Dig/CCBs, epi or neo may prevent systemic toxicity

115
Q

What is the most cardiotoxic amide?

A

Bupivacaine

116
Q

What are the 3 goals with suspected systemic LA toxicity?

A

1) Prompt airway management
2) Circulatory support
3) Removal of LA from receptor sites
(in this order per the slide, from lecture, Castillo says he would do 3, 1, 2)

117
Q

Basic interventions in CNS systemic toxicity?

A

100% O2, hyperventilate, barbiturates/benzos/propofol for seizures, epinephrine

118
Q

What is the best pharmacologic treatment LA systemic toxicity?

A

Lipid rescue

119
Q

What is the dose for lipid emulsion in lipid rescue? Adjunct medication? Last ditch effort if it doesn’t work?

A

Bolus: 1.5 ml/kg of 20% lipid emulsion
Infusion: 0.25 ml/kg/minute for 10 minutes
Adjunct: 10 - 100mcg of epi
Last ditch resort: CPB (cardiopulmonary bypass)

120
Q

Max dose of lipid rescue?

A

8 ml/kg

121
Q

What are the 3 categories of neural tissue toxicity (make sure to say toxicity in your best Serj Tankian voice)?

A

Transient Neurologic Symptoms (TNS)
Cauda Equina Syndrome
Anterior Spinal Artery Syndrome

122
Q

Describe the pathophysiology of transient neurologic symptoms (TNS)

A

Moderate to severe pain (lower back, buttocks & posterior thighs) within 6 to 36 hours after uneventful single-shot SAB

Cause = unknown, seen more often with lidocaine

Tx = Trigger point injection and NSAIDs

Generally recover in 1-7 days

123
Q

Describe the pathophysiology of cauda equina syndrome

A

Diffuse injury @ lumbosacral plexus  varying degrees of sensory anesthesia, bowel & bladder sphincter dysfunction, & paraplegia

Associated: large lumbar disc herniation, prolapse or sequestration with urinary retention.

Cause = unknown

124
Q

Describe the pathophysiology of anterior spinal artery syndrome

A

Lower extremity paresis with a variable sensory deficit.

Cause: uncertain if its thrombosis or spasm of the bilateral anterior spinal artery

Other etiologies = effects of hypotension or vasoconstrictors drugs; PVD, spinal cord compression d/t epidural abscess or hematoma

125
Q

Prilocaine and benzocaine are the 2 LAs most likely to have MetHgb issues, what 4 other drugs may also create MetHgb?

A

Lidocaine, nitroglycerine, phenytoin and sulfonamides

126
Q

Lidocaine toxicity effect on respirations?

A

Lidocaine depresses the ventilatory response to arterial hypoxemia, making this condition particularly dangerous in COPD patients

127
Q

What is the common cause of hepatotoxicity related to LA use?

A

Treatment of post-herpetic neuralgia using bupivacaine

128
Q

What parturient effects does cocaine have?

A

Decreased uterine blood flow = fetal hypoxemia

129
Q

What intermediate-acting NMBD has the longest time to maximal block?

A

Cisatracurium

130
Q

What are the anti-cholinergics paired with our AChE inhibitors?

A

Atropine and glycopyrrolate

131
Q

What organ primarily clears pyridostigmine and edrophonium?

A

The kidneys, around 75%

132
Q

What twitches constitute a moderate block? Deep block?

A

Mod = the 2nd twitch appears during a TOF
Deep = if twitch recovery requires 1-2 post-tetanic counts

133
Q

What amide must be avoided if pregnant?

A

Mepivacaine (prolonged elimination in the fetus/newborn)

134
Q

What is the extended release name of bupivacaine?

A

Exparel

135
Q

What ester LA is the most protein bound?

A

Tetracaine

136
Q

What is the dose of lidocaine in tumescent LA?

A

35 - 55 mg/kg

137
Q

How much lidocaine can each gram of subQ tissue absorb?

A

1 mg

138
Q

What preservative is found in both esters and amides?

A

Methylparaben

139
Q

What is the max dose of glycopyrrolate?

A

1 mg

140
Q

In order for sugammadex to exert it’s effect, what state must the drug be in?

A

Unbound or free drug in plasma

141
Q

When does recurarization occur with sugammadex?

A

With too low of a dose

142
Q

What amide is the most protein bound? least?

A

Most = levobupivacaine
Least = prilocaine

143
Q

What amide is closest to physiologic pH?

A

Mepivacaine

144
Q

What LA has the highest lipid solubility?

A

Tetracaine

145
Q

What fast ester and slow amide may be combined?

A

Chloroprocaine and bupivacaine

146
Q

Generic name of Sux?

A

Anectine

147
Q

Generic name of Cisatracurium?

A

Nimbex

148
Q

Generic name of Vecuronium?

A

Norcuron

149
Q

Generic name of Rocuronium?

A

Zemuron

150
Q

Generic name of Pancuronium?

A

Pavulon

151
Q

What ester has the shortest duration? Longest?

A

Short = Chloroprocaine
Long = Tetracaine

152
Q

What amides have the shortest duration (2 of them)?

A

Lidocaine and prilocaine

153
Q

What amides have the longest duration (3 of them)?

A

Bupivacaine, levobupivacaine and ropivacaine

154
Q

What amide is broken down by CYP450?

A

Ropivacaine

155
Q

What amide LA administration is not improved with concomitant administration of epi?

A

Bupivacaine

156
Q

Do motor or sensory fibers need a higher concentration of LA? Why?

A

Motor; because they have 2x the diameter they need more LA to anesthetize

157
Q

If the pKa of a weak base is 9.1 is it more ionized or non-ionized?

A

Ionized

158
Q

If the pKa of a weak base is 4.5 is it more ionized or non-ionized?

A

Non-ionized

159
Q

Describe the concentration of tumescent liposuction solution

A

Lidocaine 0.05 - 0.1%
Epi at 1:100,000 or 10 mcg/ml

160
Q

What esters are not effective as topical agents?

A

Procaine and chloroprocaine

161
Q

What esters may be used topically?

A

Cocaine and tetracaine

162
Q

What amide has the highest possible dose you can give?

A

Prilocaine

163
Q

What ester has the highest possible dose you can give?

A

Chloroprocaine

164
Q

What amide has the highest lipid solubility?

A

Bupivacaine

165
Q

What amide is metabolized the fastest?

A

Prilocaine

Semester 2 TxWes (16 decks)

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