Pharmacology Flashcards
Which of the following herbal supplements is linked to an increased risk of bleeding and prolonged emergence?
Ginkgo biloba
The anesthesiologist is performing a digital block with a 50/50 mix of Lidocaine and Bupivacaine. What is the purpose of mixing these medications?
Lidocaine is fast acting and Bupivacaine is long acting. The mixture provides the advantages of both
Atropine is given to the patient just before induction in surgery. Atropine will help prevent bradycardia during induction. In what other way does atropine benefit the surgical patient?
it inhibits oral secretions
Albuterol or glycopyrrolate may be used to
control secretions
Your patient is having cataract extracapsular extraction with implantation of an intraocular lens which medication would you question giving?
Pilocarpine
The lens is delivered through a small incision in the junction of the cornea and sclera. Any medication that contracts the pupil would make
this very difficult. Pilocarpine is a medication
used to treat glaucoma and it causes the pupil
to constrict.
St. John’s Wort
can prolong anesthesia,
Echinacea
Can cause liver damage
Ephedra
Cardiac effects especially when paired with atropine
Unexpectedly, the 16-year-old female is displaying a Wide Complex QRS on her ECG immediately upon arrival in the OR. She is sweating and is becoming cyanotic. She has a weak rapid pulse. The CRNA applies oxygen and opens the IV fluid to run by gravity. The nurse expects anesthesia will give which of the following medications first?
Amiodarone
Wide Complex QRS can be either VT or SVT. In an adolescent the observable symptoms can be very similar. An adolescent or child may sometimes have a pulse with VT. If clinicians are unsure it’s always assumed to be VT and treated as such first.
Amiodarone followed by synchronized cardioversion is the treatment for VT with a pulse.
The cardioversion will also correct SVT.
Decades ago Lidocaine was given IV but this is an outdated treatment. The Berry and Kohn book still says to use Lidocaine for VT
The trade name for sublimaze (generic name)
Fentanyl
-100 times stronger than morphine
-Push slowly
Trade name for diazepam (generic name)
Valium
-Benzodiazepine
-Burns on IV administration
-Potent respiratory depressant
Dilaudid is trade name for
Hydromorphone (generic name)
-push slowly, can cause chest wall rigidity
-7 times more potent than morphine
Trade name for versed
Midazolam (generic name)
Fasciculation to which depolarizing muscle relaxant
Succinylcholine chloride (Anectine)
Midazolam (versed)
Benzodiazepine
-Amnesic/anti-anxiety
-Used for general, regional, and moderate sedation
-short acting
Fentanyl (Sublimaze)
Narcotic analgesic- opioid
Use with caution in head injuries, bradycardia, CNS depressants, GI obstruction
Adverse reactions: respiratory depression, arrest, laryngospasm
*Romazicon (flumazenil)
Reversal for benzodiazepine (diazepam, midazolam)
-contraindicated in patients with seizures and those taking tricyclic antidepressant
Naloxone (Narcan)
Opioid reversal for fentanyl, sufentanil, morphine, demoral, dilaudid
Herbal supplements- Alter or prolong anesthesia
Kava kava
St. John wort
Valerian
Black cohosh
Herbal supplements- increase blood pressure
Ephedra
Ginseng
Licorice
Green tea
Herbal supplements- anticoagulant effects
Aloe Vera
Chamomile
Cinnamon
Garlic
Ginger
Ginkgo biloba
Cayenne pepper
Ginseng
Licorice
Some fish oils
Vitamin E
Green tea
Turmeric
Rights of medications
- Right patient.
- Right medication.
- Right dosage.
- Right time
- Right route.
- Right strength and concentration (new)
- Right infusion rate (New)
Compounding medications
No more than three meds mixed together, unless by pharmacy
What is the new expiration date of medication when withdrawn from multidose vial?
28 days from initial use
Acetyl salicylic acid therapy (aspirin) should be stopped
2 weeks before surgery
First choice to treat bronchospasm
Inhaled bronchodilators
Local and moderate sedation can be done by RN for which classes?
ASA 1-3
-no beard, dentures, or sleep apnea (difficult mask ventilation)
Neuraxial anesthesia – epidural
Is placed in space before Dura
Catheter remains in place
Neuraxial anesthesia– spinal
Goes into Dura
Very small needle, in and out
When are patients at increased risk for an MI?
Induction and 2 to 3 days after surgery
Sedative-hypnotics – Etomidate
“ vomit date”
Need antiemetic
Midazolam initial dose
1-2.5mg IV over 2 minutes until slurred speech/sedation
Midazolam adverse reactions
apnea
geriatrics require smaller dose/longer wait
Meperidine (Demerol)
Weak opioid used for shivering 
Duramorph (Morphine)
High incidents of nausea/vomiting
-morphine and codeine are naturally occurring opioids
Narcan dosage
0.1-2mg IV q 2-3 minutes prn
-Start with small doses, want to partially reverse
-Not completely (painful)
Narcan adverse reactions
Vtach
Vfib
cardiac arrest
Narcan common reactions
hypertension
N/V
withdrawal
diaphoresis
Narcan duration
30-45 minutes
Monitor for return of respiratory depression
Flumazenil dosage
0.2mg IV q min x 1-5 doses
Maximum is 1mg total dose
Flumazenil adverse reactions 
seizures
arrhythmias
resedation
Flumazenil common reactions
dizziness
N/V
diaphoresis
blurred vision
Depolarizing agents- succinylcholine
-Only depolarizing agent
-Used primarily for induction to facilitate tracheal intubation
Succinylcholine onset
1 minute
Succinylcholine duration
5 to 10 minutes
What is succinylcholine metabolized by?
Pseudocholinesterase
-not the normal process of acetylcholinesterase
-Takes longer
-People lacking the enzyme, have to stay intubated as it takes days to get rid of
Succinylcholine adverse reactions
Bradycardia
Increases intraocular pressure, contraindicated for glaucoma
Hyperkalemia
Oxygen depletion
Succinylcholine contraindications
Malignant hyperthermia family history
Degenerative neuromuscular disorders
-no reversal agent
Non-depolarizing muscle relaxants (NDMR)
Acetylcholine competitive antagonists
-Blocking agents
-all work slower than succinylcholine
-large doses rocuronium come close
NDMR reversal agents
Anticholinesterases
-typically combined with a muscarinic antagonist (anticholinergic)
-Glycopyrrolate (always mixed with neostigmine)
-Atropine (pre-mixed with edrophonium)
Sugammadex
Selectively binds rocuronium or vecuronium
-is able to reverse any depth of neuromuscular block due to its 1:1 binding
-Not an anticholinesterase
Inhalation gases – halothane
Strongest
Can cause arrhythmias in conjunction with Epi
Associated with MH
Inhalation gases- isoflurane
Rapid recovery (lucid in 15 to 30 minutes)
Can’t be used with tourniquet
Stinks, patients throw up
Inhalation gases – sevoflurane
Rapid onset and offset
Sweet taste
Inhalation gases – ethrane
Contraindicated in people with seizures
Inhalation gases – desflurane
Fastest onset and offset
Coughing is common
Inhalation gases – nitrous oxide
Gas
Odorless
Can support combustion like oxygen
Diffusion hypoxia
Inhalation gases
All volatile agents, except for nitrous oxide
Not reversible, have to breathe it out
What are Malignant hyperthermia triggers?
-A genetically susceptible patient
-Succinylcholine is one of the most common triggers
-Especially when used in conjunction with an inhaled anesthetic, such as desflurane, isoflurane, and halothane
Malignant hyperthermia, early signs
-Trismus (jaw tightening, biting tube)
-Rapid increase in body metabolism (rise in exhaled CO2)
-Intense muscle rigidity
-Increased heart rate
-Increased blood pressure
Malignant hyperthermia late signs
-rapidly rising body temperature
-Changing color of soda lime
-Hyperkalemia
-Hypoxia (O2 demand higher than what can be given)
-Myoglobinuria (tea colored urine, broken down muscle)
-Cardiac arrest
Malignant hyperthermia treatment
-Immediately discontinue all triggering agents, change circuit
-Hyperventilate the patient with 100% oxygen
-Call MHAUS
Medication for malignant hyperthermia
Dantrolene
2 to 3 mg per kilogram
Mix with sterile water
Medication for metabolic acidosis with malignant hyperthermia
Sodium bicarbonate IV
Medications for hyperkalemia in malignant hyperthermia
Calcium
Insulin
Glucose
Medications for myoglobinuria in malignant hyperthermia
Diuretics
Bicarb
Fluids
Malignant hyperthermia treatment continued
-no calcium channel blockers
-Ice packs/hypothermia blanket
-Give iced NSS, avoid ringers
-Send labs, correct electrolyte imbalances
-Monitor ECG, correct arrhythmias
-Transferred patient to ICU when stable and monitor for 36 hours for recurrence and complications
Atropine
Contraindicated for patients with glaucoma
