Pharmacology Final Flashcards
(3) Natural catecholamines
Epinephrine, Norepinephrine, and Dopamine
(2) synthetic catecholamines
Isoproterenol and Dobutamine
(2) Synthetic Non-Catecholamines
Ephedrine and Phenylephrine
Which catecholamines do not stimulate Alpha?
Isoproterenol and Dobutamine
Which catecholamine has no affect on Beta-1?
Phenylephrine
Which catecholamines have a negative effect CO and HR?
Norepinephrine and Phenylephrine
Which catecholamines cause the greatest increase in peripheral vascular resistance?
Norepinephrine and Phenylephrine
Which (3) catecholamines cause the greatest decrease in airway resistance?
Epinephrine, Isoproterenol, and Ephedrine
Which catecholamine has a direct and indirect mechanism of action?
ephedrine
Which catecholamines cause the greatest increase in MAP?
Norepinephrine and Phenylephrine
Example of Prototype Sympathomimetic
Epinephrine
Where is Epineprhine synthesized and stored?
adrenal medulla
Why shouldn’t Epi be given orally?
rapidly metabolized by the GI and liver
What explains Epi’s lack of cerebral effects?
poor lipid solubility
Primary locations of Alpha-1 receptors
cutaneous, splanchnic, and renal vascular beds
Which catecholamines have the greatest risk of dysrhythmia?
Epinephrine and Isoproterenol
How does epinephrine affect the cardiac cycle?
accelerates rate of spontaneous depolarization (phase 4)
- increases HR
- increases likelihood of dysrhythmia
Avoidance of Epi in Beta Blockades
Epi induces bronchoconstriction from stimulation of alpha-receptors in the presence of a beta-blockade
Which catecholamine has the greatest effect on metabolism?
Epinephrine
Ocular effects of Epinephrine
mydriasis
(dilation of the pupil)
(3) Coagulation effects of Epinephrine
- accelerates coagulation due to hypercoagulable state
- increases total leukocyte, but causes eosinopenia
- increases factor V activity
Synthesis and storage of Norepinephrine
postganglionic sympathetic nerve endings
Norepinephrine produces arterial and venous vasoconstriction in all vascular beds except in _____
coronary arteries
- Norepinephrine dilates coronary arteries
Why should Norepinephrine be used cautiously in patients with right ventricular failure?
increases venous return and pulmonary artery pressure
Pathway of Catecholamine Systhesis
Phenylalanine
Tyrosine
Dopa
Dopamine
Norepinephrine
Epinephrine
Unique features of Dopamine
able to increase contractility, renal blood flow, GFR, sodium excretion, and urine output simultaneously
Renal dose of Dopamine
1 - 3 ug/kg/min
increass splanchnic and renal blood flow
Negative side effects of Dopamine
tachycardia and increase PVR
- not good for right heart failure
Most potent sympathomimetic with Beta activity
Isoproterenol
Clinical uses for Isoproterenol
heart block and RV failure
Clinical uses for Dobutamine
CHF, weaning from CPB, and pulmonary hypertension
Effects of Ephedrine
increases:
HR, CO, BP, and coronary blood flow
In which two disease states is Phenylephrine particularly useful?
aortic stenosis and CAD
- increases coronary perfusion without chronotropic side effects
Phenylephrine Overdose
activates SNS
(hypertension, tachycardia, and baroreceptor-mediated bradycardia)
- Phentolamine
- alpha-1 antagonist
- may use NTG and nitroprusside
- beta blockers are contraindicated
(3) most common Beta-2 Agonists
Albuterol, Metaproterenol, and Terbutaline
In addition to bronchospasm, what else can Beta-2 Agonists treat?
premature uterine contractions
(tocolytics)
Clinical uses for Digoxin
supraventricular tachydysrhythmias
(paroxysmal atrial tachycardia, A-fib, A-flutter)
Digoxin Features
cardiac glycoside that decreases conduction through the AV node
- IV onset 10-30 minutes
- inhibits Na+/K+ ATPase
- increases CO, SV, renal perfusion
- decreases LVEDP
- can co-administer with beta blockers
(5) Causes of Digoxin Toxicity
- renal dysfunction
- hypoxemia
- hypokalemia
- hypercalcemia
- hypermagnesemia
EKG changes in Digoxin
scaphoid effect

Diagnosis of Digoxin Toxicity
anorexia, nausea, and plasma concentration
- will also see EKG changes
- arrhythmias
- long PR and heart block
Treatment of Digoxin Toxicity
- correct the causes
- treat cardiac dysrhythmias
- phenytoin, lidocaine, or atropine
- temporary pacemaker
- if complete heart block
Contraindications for Digoxin
HOCM and WPW
Hypertrophic Obstructive Cardiomyopathies (HOCM)
idiopathic LVH and subaortic stenosis
- leading cause of death in young athletes
- Digoxin contraindicated
Wolff-Parkinson-White Syndrome (WPW)
pre-excitation syndrome due to secondary accessory AV pathway (bundle of Kent)
- EKG shows delta wave and short PR interval
- “circus rhythm”

(5) Adverse Drug Interactions with Digoxin
- Quinidine
- Succinylcholine
- Sympathomimetics with B-agonist effects
- IV calcium
- some diuretics
Effects of Phosphodiesterase Inhibitors
positive inotropic effects with vasodilation
- act independently of B-receptors; therefore, effective in B-blocked patients
- enhance actions of catecholamines
- improves location of Starling curve
(2) Types of Phosphodiesterase Inhibitors
Amrinone and Milrinone
Total serum calcium includes:
Ca2+ bound to albumin, complexed with citrate and phosphate, and free (ionized) Ca2+
- free calcium is the active ion that can be measured
Events needing Calcium
- massive transfusion
- calcium binds to the citrate in PRBCs
- CP bypass
- due to multiple units of blood
- parathyroidectomy
- if hyperparathyroidism
How is Calcium Chloride administered?
through a central line
- has a very low pH
- always aspirate line first
Another term for the Sympathetic system
thoraco-lumbar
Another name for the Parasympathetic System
Cranio-Sacral
Major tissues affected by Alpha-1
Smooth muscle and sphincters
Major tissues affected by Alpha-2
nerve endings
Major tissues effected by Beta-1
Cardiac and Kidney muscle
Major tissues effected by Beta-2
smooth muscle, bronchi, liver, and skeletal muscle
Major tissue effected by Beta-3
Adipose
Major tissue effected by DA-1
Smooth muscle, renal, mesenteric, and cardiac
Major functions of Alpha-1
contraction and constriction
Major function of Alpha-2
decrease transmitter release
Major function of Beta-1
increase HR, contractility, and renal secretion
Major function of Beta-2
relax smooth muscle
increases gluconeogenesis, glycogenolysis, and potassium uptake
Major function of Beta-3
increase lipolysis
Major function of DA-1
relax renal vascular smooth muscle
(higher doses activates Beta-1 and alpha-1)
What two enzymes inactivate catecholamines?
MAO and COMT
Dose of Epinephrine for Cardiac Arrest
0.1 mL/kg of 1:1000 via ETT
or
0.1 mL/kg of 1:10,000 via IV/IO
Epinephrine dose for Status Asthmaticus
0.01 mg/kg of 1:1000 sq
(2) Non-Selective Alpha Antagonists
Phentolamine and Phenoxybenzamine
(4) Alpha-1 Antagonist
Prazosin, Doxazosin, Terazosin, and Tamulosin
-osin
(2) Alpha-2 Agonists
Clonidine and Dexmedetomidine
(2) Combined Alpha and Beta Antagonists
Lavetolol and Carvedilol
Which part of the nervous system uses Norepinephrine (rather than acetylcholine)?
sympathetic post-ganglionic
Alpha-2 (CNS) agonist acts like an ______ antagonist
Alpha-1
Phentolamine
(regitine)
non-selective alpha antagonist
- peripheral vasodilation and decrease BP
Phentolamine Clinical Uses
treatment for acute hypertensive emergencies
- pheochromocytoma
- autonomic hyperreflexia
Phenoxybenzamine
(dibenzyline)
non-reversible and non-selective Alpha Antagonist
- used preoperatively for Pheochromocytoma
- Raynauds
- preferentially dilates cutaneous arteries
Pheochromocytoma
tumor of the adrenal medulla
- secretes excessive amounts of Epi and NE
- Malignant hypertension
Pheochromocytoma
(preoperative preparation)
- alpha blockade
- phenoxybenzamine
- add CCB if needed
- Beta blocker for tachycardia
- fluid replacement
In a patient treated with propranolol and phenoxybenzamine prior to resection of a solitary pheochromocytoma, would you expect postoperative hypotension or hypertension?
Hypotension
- hypovolemia
- residual BB and alpha blockade
- adrenal insufficiency
Doxazosin
(cardura)
Alpha-1 Antagonist
- treatment for hypertension and BPH
- relaxes prostatic and vascular smooth muscle
Prazosin
(minipres)
alpha-1 Antagonist
- used for HTN and CHF
- dilates arterioles and veins
Terazosin
(hytrin)
Alpha-1 Antagonist
- used for BPH
- relaxes prostatic smooth muscle
Tamulosin
(flomax)
Alpha-1 Antagonist
- used for BPH
- may cause orthostatic hypotension and syncope
Alpha-2 Receptor Agonists
bind pre-synaptically and reduce NE release
- mostly in CNS
- uses a negative feedback mechanism
Clonidine
centrally-acting Alpha Agonist
- decreases HR and BP
- added to regional anesthetics
Dexmedetomidine
Alpha-2 Agonist
- sedative and analgesic
- central sympatholytic effects
- avoid in liver failure
(3) Non-selective Beta Antagonists
Propranolol, Labetalol, and Sotalol
Blockade of Beta-1 in the kidney
decreases renin
- vasodilation and decreased BP
- decreased aldosterone
- salt and water retention
- decreased NE release
Best drug for controlling Torsades de Pointess in patients with prolonged QTc
Propranolol
Best drugs to give patients with CHF
Metoprolol and Carvedilol
Labetalol
(normodyne and trandate)
Alpha-1 and non-selective Beta Antagonist
- used for hypertension and controlled hypotension
- 1 - 5 min onset
Treatment for Beta Blocker Toxicity
- Atropine
- Isoproterenol
- Dobutamine
- Glucagon
- Calcium Chloride
Blockade of Beta-2 receptors in the bronchi will cause _____
bronchoconstriction
Why should Beta-1 blockers be used with caution in diabetic patients?
can impair receovery from hypogylcemia and mask symptoms of hyperglycemia
Which beta blocker does not cross the placenta?
esmolol
Contraindications to Beta Blockers
- heart blocks and sinus arrest
- hypovolemic patients with compensatory tachycardia
- COPD (relative)
- conditions that would result in unopposed alpha stimulation
- cocaine and pheochromocytoma
Propranolol decreases the clearance of _____ local anesthetics
amide
- increased LA toxicity
- especially bupivicaine
Esmolol
(brevibloc)
short-acting Beta-1 Antagonist
- fast onset and half-life
- hydrolysis by plasma esterases
Metoprolol
(lopressor)
Beta-1 Antagonist
- large doses become non-selective
Atenolol
(tenormin)
most selective Beta-1 Antagonist
- used in CAD patients at high risk of MI
Timolol
Beta Antagonist
- eyedrops used for Glaucoma
- systemic absorption can cause bradycardia and increase airway resistance
Carvedilol
(coreg)
Alpha-1 and non-selective Beta Antagonist
- weak vasodilator
- treats mild CHF and hypertension
Which types of CCB are selective for the AV node?
Benzothiazepines and Phenylalkylamines
Which type of CCB is selective for arteriolar beds?
Dihydropyridines
Calcium Channel Blockers
decrease HR by decreasing the speed of conduction through the SA and AV node
- reduce contractility and relax vascular smooth muscle
- treats coronary spasms, angina, and SVT
(1) Benzothiazepine example
Diltiazem
(1) Phenylalkylamine example
Verapamil
Verapamil
CCB
(phenylalkylamine)
- slows conduction through AV node
- negative chronotropic effect on SA node
- avoid in WPW
Nifedipie
CCB
(dihydropyridines)
- coronary and peripheral arterial vasodilation
- no AV or SA node depression
Which CCB has the greatest vasodilating effects?
Nicardipine
Nimodipine
CCB
(dihydropyridine)
- CNS vasodilation of large cerebral arteries
- good for cerebral vasospasm following sub-arachnoid hemorrhage
What causes cerebral vasospasms?
influx of Ca2+ ions causing contraction of smooth muscle cells in large cerebral arteries
Diltiazem
(cardizem)
CCB
- selective for AV node
- used for SVT and angina
(benzothiazepine)
Which (2) CCB increase risk of LA toxicity
Verapamil and Diltiazem
(4) ACE inhibitor examples
Captopril, Enalopril, Lisinopril, and Ramipril
-pril
ACE Inhibitors
treat hypertension secondary to increases renin production
- may delay onset of renal disease in DM
- no bronchospasm or bradycardia
ACE Inhibitor side effects
cough and hypotension
(4) ARB examples
candesartan, losartan, valsartan, and telmisartan
-sartan
Angiotensin Receptor Blockers (ARB)
blocks vasoconstrictive action of Angiotensin II
- no cough or allergy symptoms
Aliskiren
(teckturna)
direct renin inhibitor
Nitric Oxide
pulmonary arterial dilator used for primary pulmonary hypertension
- improves V/Q mismatch
- administered via inhalation
Nitric Oxide Complications
- Methemoglobinemia
- treat with IV methylene blue
- withdrawal symptoms
- Silo-Filler’s disease
Sodium Nitroprusside (SNP)
direct-acting peripheral vasodilator
- relaxes arterial and venous smooth muscle
- immediate onset and short duration
- requires A-line
Nitroprusside and Cyanide Toxicity
tachyphylaxis, metabolic acidosis, and increased mixed venous PO2
- 2 mcg/kg/min
- children at greater risk
Cyanide Toxicity Treatment
- 100% oxygen
- sodium thiosulfate
- sodium nitrate
- methylene blue
Nitroglycerin
venodilator and large coronary artery dilator
- used for cardiac ischemia, reduce preload in CHF, and controlled hypotension
Nicardipine
cerebral and coronary vasodilator
- IV infusion for control of BP
Hydralazine
direct arterial vasodilator
- good for CHF
- not indicated in ischemia or coronary disease
- reflex tachycardia and increased contractility
Fenoldopam
Dopamine-1 agonist
- systemic arterial dilation
- increases renal and splanchnic blood flow
- increases urine output
Carbonic Anhydrase Inhibitors
diuretic used for altitude sickness and glaucoma
- proximal convoluted tubule and collecting duct
- decreases reabsorption of Na+, HCO3, and water
Acetazolamide
(diamox)
carbonic anhydrase inhibitor
- treats altitude sickness and glaucoma
Carbonic Anhydrase side effects
metabolic acidosis
Loop Diuretics
most potent diuretic
- acts on thick ascending Loop of Henle
- inhibits reabsorption of Na+, K+, and Cl-
- Treats CHF
(2) Loop Diuretic examples
Furosemide and Bumetanide
Loop Diuretic side effects
ototoxicity, alkalosis, and hypokalemia
- nephrotoxicity
- aminoglycoside antibiotics
- cephalosporin
- increased lithium levels
Thiazide Diuretics
used for long-term treatment of hypertension
- acts on cortical ascending Loop of Henle
- inhibits Na2+ reabsorption
- increases excretion of Na+, K+, and Cl-
Thiazide Diuretic side effects
hypokalemia, hypochloremia, metabolic alkalosis, and diabetes
Osmotic diuretic
inert substances that cause osmotic diuresis in the proximal renal tubules and Loop of Henle
- example: mannitol
- used for increased ICP
Mannitol
osmotic diuretic
- draws fluid from intracellular to extracellular space
- increases renal blood flow
- may protect transplanted kidneys
- lowers ICP
Mannitol side effects
rebound intracranial hypertension and hyperosmolarity
Potassium-Sparing Diuretics
adjunct to other diuretics
- two categories
- pteridine and aldosterone receptor blockers
- Na+ excretion without K+ excretion
Pteridine analogs
Triamterene (dyazide) and Amiloride
- prevent Na+ reabsorption in the cortical collecting duct
- blocks ENa+ channels
Spironolactone
Aldosterone receptor blocker
- prevents the synthesis and activation of aldosterone via Na-K-ATPase pump
Atrial Natriuretic Peptide
endogenous substance produced in response to myocardial wall stretch
- acts on collecting duct
- Nesiritide
- synthetic ANP for CHF
PNS and the respiratory system
- regulates airway caliber and glandular activity via the Vagus nerve
- Ach activates muscarinic receptors
- bronchoconstriction
- anticholinergics produce vasodilation
Nonadrenergic-Noncholinergic system (NANC)
ANS derived influences on the bronchomotor tone through excitatory and inhibitory peptides
(2) Short-Acting inhaled adrenergic agonists
albuterol and metaproterenol
(2) Long-Acting adrenergic agonists
salmeterol and formoterol
example of short-acting inhaled cholinergic antagonist
ipratropium
Long-acting inhaled cholinergic antagonist
tiotropium
Ipratropium
(atrovent)
inhaled cholinergic antagonist
- short acting
- used for COPD maintenance and asthma rescue
Tiotropium
(spiriva)
inhaled cholinergic antagonist
- long acting
- maintenance of COPD
COPD and Asthma involve which similar cells in inflammation?
macrophages, lymphocytes, and eosinophils
Asthma: mast cell
COPD: neutrophils
example of inhaled corticosteroid
(monotherapy)
fluticasone
-nide or -sone
Inhaled Corticosteroids
reduce inflammation
- combine with long-acting Beta-2 agonist
(2) Leukotriene Antagonists
Montelukast and Zafirlukast
(1) Leuketriene inhibitor
Zileuton
Cromolyn
mast cell stabilizer
- prevents the release of histamine
(2) Methylxanthines
Theophylline and Aminophylline
IV anesthetic bronchodilators
propofol, ketamine, and midazolam
(3) major causes of right heart failure
COPD, primary pulmonary hypertension, and OSA
Four classes of Pulmonary Hypertension
I - normal
IV - right heart failure
Ketamine
NMDA antagonist
- stimulates release and inhibits uptake of catecholamines
- maintains SVR
- prevents right-to-left shunting
- maintains coronary perfusion pressure
Propofol
GABA agonist
- decreases SVR
- increases right-to-left shunt
- may lead to right heart failure
Etomidate
GABA agonist
- no change in SVR
- coronary perfusion pressure maintained
- no change in R-to-L shunt
Which neuromuscular blocker increases PVR?
pancuronium
sympathetic stimulation ______ PVR
increases
all volatile agents ____ HPV
inhibit
(although modern agents are very weak dilators)
Management of PHTN
reduce right ventricular afterload while preserving coronary perfusion
(4) phases of clot formation
initiation, amplification, propagation, and stabilization
Thrombin
converts fibrinogen to fibrin
Factor XIII
promotes cross-linking of fibrin polymers to form a stable clot
(3) Anti-Coagulation agents
NO, prostacyclin, and anti-thrombin
Thrombomodulin
activates Protein-C and keeps thrombin at site of injury
Tissue Plasminogen Activator
(t-PA)
activates plasmin from plasminogen
Protein C
inhibits factors Va and VIIIIa
VII is part of the _____ system of the coagulation cascade
Extrinsic
Prothrombin Time (PT)
evaluates the extrinsic and common pathways
- affected by reductions in prothrombin, V, VII, and X
International Normalized Ratio (INR)
standard measurement of PT
0.08 - 1.2
Partial Thromboplastin Time (PTT)
assess intrinsic pathway
Heparin
Activated Clotting Time (ACT)
used to measure high doses of Heparin
90-150 seconds
Bleeding Time
general measure of platelet function
3 - 10 minutes
Laboratory findings in Warfarin
(or Vitamin K deficiency)
prolonged PT and slightly prolonged PTT
Laboratory findings in Von Willebrand’s disease
prolonged PTT and bleeding time
Laboratory findings in Aspirin
prolonged bleeding time
Laboratory findings in Factor V deficiency
prolonged PT and PTT
DIC
Disseminated Intravascular Coagulation
Disseminated Intravascular Coagulation (DIC)
consumption of platelets and an inability to prevent thrombin formation
- coagulopathy and bleeding
- 10-50% mortality
- caused by a pathological activation of the hemostatic system
DIC diagnosis
- continued bleeding, petechiae
- low fibrinogen
- D-dimer levels (fibrin split products)
Hemophilia A
factor VIII deficiency
Hemophilia B
factor IX deficiency
TRALI
Transfusion Related Acute Lung Injury
Type A Blood
contains A antigens
(anti-B antibodies)
When would you use FFP?
urgernt reversal of warfarn
“unit” of blood
10% of patient’s estimated blood volume
Cryoprecipitate
precipitate of frozen plasma
- contains factor VIII, XIII, fibrinogen, and vonWillebrand
Leukoreduction
reduces white blood cells
- used in PRBC and platelets
- decreases exposure to non-ABO antigens and CMV
Which blood transfusions have the greatest risk of TRALI?
plasma > platelets > RBCs
Transfusion-Related Acute Lung Injury (TRALI)
hypoxia and pulmonary edema within 6 hours of transfusion
Which factors catalyze the transformation of Prothrombin to thrombin?
(II and IIa)
Factor Xa and Va
Heparin
binds to anti-thrombin to enhance coagulation
- highly charged acidic molecule
- poorly lipid soluble with a high molecular weight
Heparin Administration
IV (immediate onset)
Subcutaneous (1-2 hours)
Heparin side effects
hemorrhage, spinal hematoma, and allergic reactions
aPTT
(activated plasma thromboplastin time)
30 - 35 seconds
Heparin
Enoxaparin
(lovenox)
low-MW Heparin
- anti-factor Xa
- no PTT necessary
HIT
Heparin Induced Thrombocytopenia
Heparin Induced Thrombocytopenia
- Type I
- drug induced platelet aggregation
- 3-5 days after therapy
- Type II
- immune mediated response to prior exposure to Heparin
- severe thrombocytopenia
- 6-10 days after therapy
HIT treatment
Argatroban or Lepirudin
- warfarin is contraindicated
- discontinue heparin, substitute with LMWH
Protamine
reverses heparin-induced anticoagulation
- strongly alkaline
- 1.3 mg protamine per 100 units Heparin
- administer slowly
Protamine side effets
- hypotension
- pulmonary hypertension and vasoconstriction
- bronchoconstriction
Protamine allergic reactions
fish allergies, NPH insulin, and vasectomy
- pretreat with histamine antagonist (H2 blockers)
Warfarin
(coumadin)
inhibits vitamin K
(alters prothrombin, factors II, VII, IX, and X)
- crosses the placenta
- measured by PT and INR
- does NOT alter platelet activity
Reversal of Warfarin Therapy
Vitamin K or FFP
How long should you wait before having surgery when using LMWH?
12 hours
How long should you wait before having surgery with unfractionated Heparin?
4 - 6 hours
How long should you wait before having surgery while using Warfarin?
5 days
(INR < 1.5)
Aspirin
ADP inhibitor that stops thromboxane synthesis
- irreversible effect
- COX inhibitor
Plavix
(clopidogrel)
blocks ADP on surface of platelets
- blocks platelet activation
- irreversible
(3) GIIB/IIIA antagonists
Abciximab, Tirofiban, and Eptifibatide
Bivalirudin
(angiomax)
direct thrombin inhibitor
- used in patients at risk for HIT
- monitor with ACT
(2) Direct Xa inhibitor
Rivaroxaban (xarelto)
Apixaban (eliquis)
Epsilon Aminocaproic Acid (EACA)
lysine analog that prevents lysis of clots
(anti-fibrinolytic)
Tranexamic Acid
anti-fibrinolytic
Massive Blood Transfusion
Definition
- >10 RBC units
- transfusion of >4 RBC in 1 hour
- replacement of >50% of TBV within 3 hours
- transfusion support to loss of blood > 150mL/min
TEG
(picture)

Lepirudin
(Refludan)
used for HIT and prevention of further VTE
- monitor with aPTT
- stop 24 hours before surgery
- irreversible thrombin inhibitor
Dabigatran
(pradaxa)
used for total hip/knee, VTE, and a-fib
- monitor with thrombin times and aPTT
- stop 48 hours before surgery if normal renal function
(6) Pro-Hemostatic Agents
- anti-fibrinolytic agents
- aprotinin, tranexamic acid
- DDAVP
- Protamine
- factor concentrates
- recombinant factors
- thrombin
(6) Anticoagulants
- heparin
- warfarin
- LMWH
- direct thrombin inhibitors
- platelet inhibitors
- aspirin, plavix
- platelet glycoprotein IIB/IIIA
vomiting center
medulla oblongata
- sends signals through CN X to vagal parasympathetic fibers and sympathetic chain to muscles
Apfel scoring system
cateogorizes risk of PONV
Scopolamine
transdermal anticholinergic
- blocks transmission of impulses to the medulla
Metoclopromide
(reglan)
Dopamine Antagonist used for PONV
- increases gastric motility and contracts esophageal sphincter
- readily crosses BBB
- benzamide
Midazolam in PONV
(versed)
benzodiazepine
- decrease synthesis and release of dopamine in CRTZ
- 2 mg
Droperidol in PONV
Butyrophenone
- 0.625 - 1.25 mg
- concern for cardiac arrhythmias secondary to prolonged QT interval
Dexamethasone
Glucocorticoid for PONV
- relatively contraindicated in diabetics and obese patients
- administer slowly or burning genitals
Serotonin
5-HT3
- endogenous vasoactive substance and inhibitor neurotransmitter of CNS
- 90% present in enterochromaffin cells of the GI tract
(3) 5-HT3 Antagonists
Ondansetron (zofran)
Graniestron (kytril)
Dolasetron (anzemet)
Neurokinin-1 Antagonists
treatment for PONV
- aprepitant and fosaprepitant
- more effective when combined with dexamethasone
Sodium Citrate
(bicitra)
non-particulate antacid
- commonly used in parturients
H1 Antagonists
anti-emetic
- may cause sedation, urinary retention, and QT interval changes
- contraindicated in patients with glaucoma or taking MAO inhibitors
- examples
- Benadryl and Phenergan
Dimenhydrinate
(dramamine)
H1 Antagonist
- used for motion sickness and strabismus surgery
H1 Antagonist side effects
somnolence, dry mouth, urinary retention and QT prolongation
H2 Antagonists
inhibits histamine binding to gastric parietal cells
- examples:
- rantidine (zantac), Famotadine (pepcid)
Omeprazole
(prilosec)
proton-pump inhibitor
- increases pH and decreases volume
- crosses the BBB
Metoclopromide side effects and contraindications
- do not administer to:
- Parkinson disease
- restless leg
- MAO inhibitors
- tricyclic anti-depressants
- may cause hypotension, tachycardia, bradycardia,
- inhibitory effect on plasma cholinesterase activity
Insulin secretion
pancreatic islets of Langerhans
Insulin
(effects on cells)
- facilitates glucose diffusion into cells
- shifts intracellular glucose metabolism towards glyocogen storage
- stimulates K+ uptake and protein synthesis
Azotemia
Increased production and excretion of urea and ammonia
Type I Diabetes
auto-immune destruction of pancreatic Beta cells
- do not produce insulin
A1C
reflects glucose control over 3 months
- should be less than 7%
(2) very rapid Insulin
Humalog and NovoLog
(1) rapid-acting insulin
Humulin
(regular insulin)
(2) Long-Acting Insulin
Lantus and Levemir
Degludec
(Tresiba)
longest acting insulin
What is the only insulin that can be given IV
regular insulin
Insulin
site of injection
abdomen > arm > buttocks > thigh
Rule of 1800
calculates insulin sensitivity
- 1800/total daily dose of insulin (units)
- = reduction of glucose/unit
Assuming 60 units per day, each unit of insulin should lower blood sugar by 30 mg/dL
_____ results in a hyperadrenergic state
hypoglycemia
- tachycardia, sweating, anxiety
Glucagon
works opposite of insulin
- synthesized in pancreatic islet A cells
- reduced secretion by BB
- can cause hypoglycemia
SAMBA
glycemic control for the perioperative period
(4) types of Hypoglycemic agents
- sulfonylureas
- meglitinides
- biguanides
- thiazolidinediones
Pioglitazone
(actos)
oral hypoglycemic agent
- thiazolidinedinones
Rosiglitazone
(avandia)
oral hypoglycemic agent
- thiazolidinediones
Sulfonylureas
stimulate the release of insulin from pancreatic Beta cells
- may cause hypoglycemia
Meglitinides
stimulates insulin secretion
- fast acting and short duration
- example: Repaglinide (prandin)
Biguanides
inhibits glucose production by the liver
- example: Metformin (glucophage)
- possible lactic acidosis
Thiazolidinediones
increase sensitivity to insulin for glucose uptake by skeletal muscle
- not a risk for hypoglycemia
- Examples: avandia and actos
Levothyroxine
T4
- easily overlooked in post-op orders, may present as “failure to thrive”
Treatment of Mineralcorticoid deficiency
Fludrocortisone
(florinef)
Addison’s disease
adrenal failure where the body does not produce enough steroid hormones
- low blood pressure, nausea, vitiligo
Cushing’s Syndrome
exccess steroids
- weight gain, slow healing, fatigue, gluocse intolerance
Vasopressin
anti-diuretic hormone
- secreted by posterior pituitary
- arterial vasoconstrictor and reabsorbs water
Vasopressin side effects
- vasoconstriction and increased BP
- increased pulmonary artery pressure
- coronary ischemia
- increased peristalsis
Oxytocin
(pitocin)
indirect stimulation of uterine muscle to induce labor and reduce uterine atony
- secreted by posterior pituitary
Ocetreotide
(sandostatin)
somatostatin that inhibits release of growth hormone
- used to treat acromegaly and acute carcinoid crisis
SBE
subacute bacterial endocarditis
____ do not need to distinguish between positive and negative
anaerobes
Redose of antibiotics
2 1/2 half lives
Cefazolin
(ancef)
1st generation cephalosporin
- gram positive and negative
- cross-reacts with PCN allergy
Cefoxitin
(mefoxin)
gram positive and negative aerones AND anaerobes
Clindamycin
(cleocin)
Lincosamides
- gram positive aerobes AND anaerobes
- may prolong NMD
- may cause superinfection with C.diff
recommended antibiotic for Urologic surgery
Fluroquinolones
Ciprofloxacin
(cipro)
fluoroquinolones
- gram positive and negative
- pseudomonas
- increases serum level of Theophylline
Vancomycin
primary treatment for MRSA
- infuse over 60 minutes
- redman syndrome
Redman Syndrome
hypersensitivity to Vancomycin
- degranulation of mast cells and basophils
- flushing, red skin, hypotension
Fluoroquinolones side effects
tendonopathies
Levofloxacin
(levaquin)
Fluroquinolones
avoid in patients with Myasthenia gravis
Gentamicin
Aminoglycoside
- may cause ototoxicity, nephrotoxicity, and potentiation of NMB
- give over 60 minutes
Metronidazole
(flagyl)
treats C. diff and H. pylori
- give over 60 minutes
antibiotics contraindicated in pregnancy
fluroquinolones