Pharmacology III Exams Flashcards
DOA of cisatracurium
20-50 mins
Phenylephrine: as little as ___ mcg/kg can cause LV dysfunction
1mcg/kg
3 adverse side effects of Protamine:
- hypotension
- acute pulm vasoconstriction
- RV failure
Pitocin can cause decrease in BP significantly in
hypovolemia
general anesthesia
Hemabate dose
250mcg
methergine dose
0.2mg
versed’s elimination half time can be prolonged by
CPB
Ketamine induction dose
1-2mg/kg
propofol induction dose
1.5-2.5mg/kg
phenylephrine compared to norepinephrine is
less potent and longer lasting
labetalol DOA
2-6 hours
Esmolol DOA
30 mins
Onset of ketamine
30-60seconds
Reglan’s MOA
stimulates GIT via cholinergic mechanism, contraction of LES and gastric fundus, increased gastric and small intestinal motility, decreased muscle activity in the pylorus and duodenum.
Most common side effects of zofran (choose 2)
headache
diarrhea
direct systemic arterial vasodilator, hyperpolarizes smooth muscle cells and activates guanylate cyclase to cause vasorelaxation
Hydralazine
Typical dose of ephedrine?
5-10mg IV
Succinylcholine is known to cause hyperkalemia in all conditions except what?
severe metabolic alkalosis
What is the dose of sugammadex with a TOF of 2?
2mg/kg
Robinul dose
7-15mcg/kg
Neostigmine dose
40-70mcg/kg
Atropine DOA
1-2hr (also took 30-60mins)
Cisatracurium Choose 2:
No histamine Release
Hoffman Elimination (Hepatic metabolism??)
0.1-0.2 mg/kg
Sugammadex has an affinity MORE for which NDMB?
Roc
Fentanyls analgesic property is 75 - ___ times more potent than morphine?
75- 125
MOA of flumazenil
competitively inhibits the activity at the benzodiazepine recognition site of the GABA/Benzodiazepine receptor complex antagonistic effects of benzodiazepines
appropriate dose of ketamine for a 175lb man?
60-160mg/kg
succ short DOA is due to rapid hydrolysis by:
butyrylcholinesterase
MOA of narcan
inhibits uptake of opioids at the opioid receptor site
Methergine IV can cause (Choose 2):
Sudden HTN episodes
CVA
Protamine dosage
1mg per 100 units of circulating heparin
etomidate binds to:
GABA A
Ephedrines tachyphylaxis can be first seen with what dose:
second
which drug potentiates NMB?
Clindamycin
choices were 3 antibiotics and omeprazole
True regarding propofol (choose 2):
- ) baroreceptor reflex control of HR may be depressed by propofol
- ) Dose dependent depression of ventilation likely to occur after induction of anesthesia but painful surgical stimulation is likely to counteract the ventilatory depressant effects.
Propofol binds to:
GABA A
MOA of Rocuronium
Competes with ACh at the POSTsynaptic nicotinic acetylcholine receptor
As an analgesic, lidocaine binds to _____ channel
sodium
Something regarding epinephrine and what receptor is associated with vasodilation especially in the skeletal muscles
Beta 2
When preparing a Succ dart, you include:
1ml of Atropine (0.4mg), 2 mil of Succ (40mg), IM needle
What is true of ephedrine?
- Ephedrine cause the release of endogenous norepinephrine (indirect)
- Ephedrine causes adrenergic stimulation (direct)
Midazolam produces dose-dependent decreases in ventilation (choose 2)
a. ) in the presence of an opioid
b. ) by decreasing hypoxic drive
dantrolene dose for MH:
2.5mg/kg q 5-10 mins with max dose of 10mg
What is responsible for the rapid hydrolysis of esmolol?
plasma esterase
Chemotherapy drugs are classified according to their
Mechanism of action
Cisplatin is known to cause approximate 50% wasting of:
magnesium
All of the following are common side effects of cisplatin excepts:
an increase in seizure threshold
Methotrexate may be most useful in the treatment of acute lymphoblastic leukemia in which of the following?
8 yo male
Which of the following would be used in a rescue technique to protect damage to cells in patients taking methotrexate? (Choose 2)
Thymidine
Thyroxine
An alarming expected SE to inform a patient taking doxorubicin would be
red urine
A first sign of toxicity concern for a patient taking bleomycin would be:
Cough (early sign of pulmonary toxicity)
Your patient finished her bleomycin chemotherapy 9 mos ago. What is of concern to an astute SRNA?
The need to run O2 Concentrations for ApO2 > or = 90%
Of the vinca alkaloids, which of the following is least likely to cause bone marrow depression:
Vincristine
Which class of chemo drugs involves cardiomyopathy that occurs in 2% of pts, and is fatal approximately 3 weeks after onset of symptoms in 60% of those patients affected?
Topoisomerase inhibitors
On the skin, _____ ethyl alcohol kills nearly 90% of cutaneous bacteria within 2 mins, provided the area is kept moist
70%
Immediately after a hand scrub with ______, the cutaneous bacterial population may be decreased by only ________ compared with greater than 90% following use of an iodophor.
hexachlorophene
30-50%
Routine prophylaxis with vancomycin is not recommended for any patient population in the absence of documented or highly suspected colonization or infection with MRSA (recent hospitalization of _________ and HD patients) or _________________.
nursing home stay
Known IgE-mediated response to Beta-Lactam antibiotics
Most SSIs result from bacterial inoculation at
the time of surgery
this is a novel fifth generation cephalosporin
Ceftaroline
Evidence has documented several patient risk factors associated with higher frequency of SSIs, including diabetes, tobacco use, obesity, malnutrition, systemic steroid use or other immunosuppressive drugs, duration of the operation, and intraoperative hypothermia, NOT:
post-operative recovery
Evidence has documented several patient risk factors associated with higher frequency of SSIs, including
diabetes tobacco use obesity malnutrition systemic steroid use (or other immunosuppressive drugs) duration of the operation intraoperative hypothermia
this has the longest elimination half-time of any third generation cephalosporin
Ceftriaxone
Ceftriaxone has the longest elimination half time of any third-generation cephalosporin and is highly effective against gram-negative bacilli, especially Neisseria and _____.
Haemophilus
65 y.o. Patient with history of PNC allergy (2 weeks of ICU); Hx of CRF on hemodialysis, etc. needs treatment for MRSA.
Vancomycin because it warrants a risk of something, blah blah blah
rapid infusion of Vancomycin has been associated with
nonimmunologic histamine release ….. a sudden decrease in left ventricular filling
Most at risk for SSI:
4 year old male
glucose control is associate with an approx. 50% decrease in deep sternal infection by
continuous infusion of insulin
Characteristics of hypothermia that contribute to risk of SSI EXCEPT:
peripheral vasodilation
(Flood: “Peripheral vasoconstriction, decreased wound oxygen tension and recruitment of leukocytes, favoring infection and impaired healing)
Dose for cefazolin for pt weighing 125kg would be?
3g
anything >120kg
Clindamycin is given at 8am, when would you expect a redose?
2pm
Q6hrs
Redosing interval for Clindamycin?
6hrs
When would you expect to redose Ceftriaxone?
does not need to be redosed
Treatment for aminoglycoside induced skeletal muscle weakness
IV administration of calcium overcomes the effect of aminoglycosides at the NMJ
Aminoglycosides induce skeletal muscle weakness by:
inhibit presynaptic release of ACh
Decreasing post-synaptic sensitivity to the NT
A patient that arrives for surgery after preop dose of _____ with diarrhea. what should you test for?
Pseudomembranous colitis
A picture of Torsades de Pointes. What abx could cause this?
Erythromycin
Most common cause of bacteremia and fungemia
intravascular catheters
Which of the following would NOT contribute to 50% decrease of antimicrobial concentration in the parturient
Increased gastric emptying
other answers: increased maternal blood volume, increased GFR, increased hepatic activity
Considered safe in the use of the parturient (abx related)
Erythromycin base
PCNs
Cephalosporins
in pregnancy, which is considered safe erythromycin estolate or erythromycin base?
base
CH2 R Group
Penicillin G
CH-NH2 R group on Penicillin
Ampicillin
Insert PCN photo
ID the beta lactam ring
ID the Thiazolidine Ring
Used to prolong PCN by blocking its renal tubular secretion
Probenecid
Which of the following are penicillinase-resistant PCN: (choose 2)
Methicillin
Oxacillin
Which of the following are penicillinase-resistant PCN: (choose 2)
Methicillin
Oxacillin
(methicillin, oxacillin, nafcillin, cloxacillin, dicloxacillin)
Patient with fever, nuchal rigidity and headache pre-op. What would you give?
Nafcillin
2nd generation cephalosporin effective in tx of meningitis:
Cefuroxime
Which of the following is a false statement regarding 3rd gen. Cephalosporins:
does NOT have the same low toxicities as the older (first generation?) cephalosporins
Most nephrotoxic aminoglycoside so it’s not given parenterally is:
Neomycin
ABX used in the treatment of streptococcal pharyngitis
Erythromycin (or clindamycin)
tx streptococcal pharyngitis, bronchitis, and pneumonia
Azithromycin has an elimination half time of?
68hrs
Concurrent ingestion of alcohol may cause a reaction similar to that produced when alcohol is ingested by patients taking disulfiram
Metronidazole
Cefazolin 1gm is ordered preop for a patient with a past reaction to PCN; what abx do you give?
Clindamycin
A Bactericidal Glycopeptide antimicrobial
Vancomycin
Dose of Vancomycin=
15mg/kg (10-15mg/kg)
Dose of clindamycin =
900 mg (q6h)
Selective decontamination of the digestive tract is to eradicate: (choose 2)
- Gram -negative organisms
- Yeasts
“selective decontamination of the digestive tract with oral topical polymyxin, tobramycin, and amphotericin eradicates the colonization gram-negative microorganisms, S. aureus, and yeasts from oral cavity to rectum”
The efficacy of antimicrobial depends on:
drug delivery to site of infection
Patient has renal failure, what antimicrobial do you want to avoid ?
Penicillin G
Penicillinase -Susceptible broad spectrum penicillins (choose 2):
Ampicillin
Amoxicillin
(and carbenicillin)
Aztreonam lacks:
the dihydrothiazine ring found on cephalosporins
and the thiazolidine ring present in PCNs
this should not be used with PCN due to resulting antagonism of the bactericidal actions of PCN against some strains of Enterococcus faecalis:
Amikacin
What can anesthesia do to prevent surgical infection?
hand washing
Unique SE of Carmustine: (choose 2)
- delayed thrombocytopenia (PLT)
- delayed leukopenia (WBC)
after approx. 6 weeks of tx
All of the following affect onset of LA except?
Volume
what is the recommended dose of epinephrine for regional administration of anesthesia?
1:200,000
Over nearly three decades, droperidol, ____ IV has become widely accepted as a safe cost effective first line therapy for the management of postoperative nausea and vomiting.
0.625 to 1.25 mg IV (pg 841)
There is an associated acute reversible decrease in the ___ within 24hrs after a single dose of (Doxorubicin; topoisomerase inhibitors)
Ejection fraction
Predictive tests to permit early recognition of impending cardiomyopathy are not available, although _______ is consistent with the diffuse character of the myocardial damage.
Diminution in QRS Voltage on EKG
“Predictive tests to permit early recognition of impending cardiomyopathy are not available, although diminution in QRS
voltage on the ECG is consistent with the diffuse character of the myocardial damage” pf 816 - Doxorubicin
“diminution” - reduction in size
A mild form of pulmonary toxicity is characterized by (choose 2):
- exertional dyspnea
- a normal resting PaO2
“The first signs of pulmonary toxicity are cough, dyspnea, and basilar rales, which progress in one of two directions.
A mild form of pulmonary toxicity is characterized by exertional dyspnea and a normal resting Pao2.
A more severe form of arterial hypoxemia at rest is associated with radiographic fi dings of interstitial pneumonitis and fibrosis.”
Antibody-based therapies for treatment of cancer include the monoclonal antibodies trastuzumab, alemtuzumab, rituximab, and imatinib, which target specific antigen sites on cancer cells. The mechanisms of action of these agents
are specific and varied depending on the target
EKG changes associated with TCA’s:
flattening or inversion of the T-wave
Tricyclic antidepressants produce depression of conduction of cardiac impulses through the atria and ventricles, manifesting on the electrocardiogram (ECG)as prolongation of the P-R interval, widening of the QRS complex, and flattening or inversion of the T wave. Nevertheless, these changes on the ECG are probably benign and gradually disappear with continued therapy.28 Atropine is a useful treatment when tricyclic antidepressants dangerously slow atrioventricular or intraventricular conduction of cardiac impulses
What factors are most important in determining duration of action with LA’s?
protein binding
Included in the differential diagnosis of serotonin syndrome EXCEPT:
cholinergic poisoning
” The differential diagnosis includes malignant hyperthermia, neuroleptic malignant syndrome, and anticholinergic poisoning”
A patient taking MAOI and you are giving rocuronium on induction. What should you change regarding your dose during induction?
No change is dose required
“Responses to nondepolarizing neuromuscular blocking drugs are not altered by MAO inhibitors.”
You have a pt going to the OR that has been treated with bleomycin, what would an astute SRNA be concerned with?
BUN of 35; CR of 3.0
Patients with one or more major risk factors (preexisting pulmonary damage from bleomycin which is more likely if the total dose is greater than 450 mg, renal dysfunction, which slows clearance of the drug from the lungs and/or prior exposure to bleomycin with a 1 to 2 month period) may be higher risk for development of bleomycin –induced hyperoxic pulmonary injury in the OR
what would you expect to see in a pt with lidocaine level of 20mcg/ml?
apnea
15-25mcg/ml = apnea/coma
>25 CV depression
The hypomagnesemia that is
associated with cisplatin would lead to what requirement:
Reduce the dose of Vecuronium
“The hypomagnesemia that is
associated with cisplatin’s renal tubular injury may predispose to cardiac dysrhythmias and decrease the dose requirements for neuromuscular blocking drugs”
What is the appropriate dose of neosynephrine in pt being treated with a TCA?
~30mcg –> You want to use 1/3 of normal dose
normal dibucaine number
80
elderly woman with polypharmacy - antidiarrheal (anticholinergic) & TCA?
A. monitor for bradycardia and glyco may be a safe alternate.
“Because the anticholinergic side effects of drugs may be additive, the use of centrally active anticholinergic drugs for preoperative medication of patients treated with tricyclic antidepressants could increase the likelihood of postoperative delirium and confusion (central anticholinergic syndrome). glycopyrrolate would theoretically be less likely to evoke this type of drug interaction in patients being treated with tricyclic antidepressants”
Phenelzine has anticholinergic like SE’s and ….
may produce sedation in some patients
A. Decrease dose of Midazolam and consider glyco ?( due to sedation and glyco doesn’t cross BBB or sedate)
Causes resistance to both radiation and most chemo drugs
Hypoxia
In poorly perfused areas of some tumors, cells remain resistant to hemotherapeutic drugs because of relative hypoxia. Indeed, hypoxia causes resistance to both
radiation and most chemotherapeutic drugs (with the exception of malignancies susceptible to treatment with the mitomycins)
A patient last took their alkylating agent 3 mos ago (something of the sorts); received 100mg Succinylcholine and is having difficulty with emergence/weakness. What is this due to?
Decreased plasma cholinesterase activity by chemo drug
“Theoretically, the effects of succinylcholine may be prolonged if plasma cholinesterase activity is decreased by chemotherapeutic drugs.”
chemo drugs are classified according to their
MOA
Early reports of post op respiratory failure in bleomycin-treated patients suggested that either _______ or _______ played a role in the exacerbation of pulmonary fibrosis?
a. Arterial hyperoxia
b. Excessive crystalloid administration
Early reports of postoperative respiratory failure in bleomycin-treated patients suggested that either arterial hyperoxia or excessive crystalloid administration played a role in the exacerbation of pulmonary fibrosis.
What two medications should you be cautious in use of O2 and radiation (other than bleomycin)?
- Mitomycin
- Carmustine
Like bleomycin, mitomycin
appears to act synergistically to induce pulmonary fibrosis with thoracic radiation and oxygen therapy, suggesting the need to limit exposure of treated patients to hyperoxia.”
“Carmustine has been associated with interstitial pneumonitis and fibrosis much like bleomycin. The incidence of pulmonary toxicity is in the range of 20% to 30%, with a mortality in those affected of 24% to 90%”
Patients tolerating emotogenic drugs are
unlikely to develop PONV
Although there is no consensus on the mechanism of pain relief, current hypothesis include serotonin activity and reuptake inhibition, potentiation of CNS endogenous opioids and
Anti-inflammatory effects
What dose of Lithium will you experience seizures?
> 2 - 2.5 mEq/L
Atrioventricular heart block, hypotension, cardiac dysrhythmias, and seizures may occur when plasma concentrations of lithium are greater than 2 mEq/L
When taking care of a patient who is a chronic cannabis smoker, how would you treat this patient?
COPD
“Chronic inhalation of cannabis smoke is associated with an increased incidence
of chronic obstructive lung disease and carcinoma of the lung and larynx”
What would you need to ask a patient that recently finished their dose of Cisplatin?
numbness and tingling in extremities
“Peripheral sensory neuropathies,
paresthesias, and loss of vibratory and position sense are common findings. Most neuropathies are reversible, although symptoms may persist for months”
Vinca Alkaloid that is least likely to cause myelosuppression?
Vincristine
Vincristine is less likely than vinblastine and vinorelbine to cause bone marrow depression.
Droperidol combination with fentanyl known as Innovar, droperidol does not enhance analgesia produced by fentanyl but rather…
prolongs its DOA
“Droperidol combined with fentanyl is administered for the production of neuroleptanalgesia. A commercially
available 50:1 combination of droperidol with fentanyl was known as Innovar. This fi ed combination of drugs is not associated with enhanced depression of ventilation as compared with either drug alone. Droperidol does not enhance analgesia produced by fentanyl but rather prolongs its duration of action
Patient going back for surgery and is taking a SSRI, what would a vigilant SRNA do?
hold antiplatelet mediation after talking to surgeon
A patient taking anti androgen drug that results in osteoporosis and skeletal muscle weakness. What would be your anesthesia concerns (choose 2):
- Padding of extremities
2. decreasing dose of NMBD (due to decreased plasma cholinesterases??)
Antiandrogens are: (3)
flutamide, bicalutamide, and nilutamide
The antidepressant effect of TCAs is produced by
Blocking the reuptake of serotonin at PRESYNAPTIC terminals; INCREASING availability.
Tricyclic antidepressants act at several transporters and receptors, but their antidepressant effect is likely produced
by blocking the reuptake (uptake) of serotonin and/or norepinephrine at presynaptic terminals, thereby increasing the availability of these neurotransmitters
8 year old taking Mercaptopurine for acute leukemia and is scheduled for surgery. What would necessitate the need for canceling or delaying the surgery?
WBC 2000
PLT 50,000, etc.
The principal side effect of mercaptopurine is a gradual development of bone marrow depression manifesting as thrombocytopenia, granulocytopenia, or anemia several weeks after initiation of therapy.
TCAs may enhance the CNS effects of
Enflurane
Treatment with tricyclic antidepressants may enhance the CNS-stimulating effects of enflurane
Caution in acute administration of TCAs with:
Ephedrine
It would appear that for patients recently started on tricyclic antidepressants, exaggerated pressor responses should be anticipated whether or not direct-acting or indirect-acting
sympathomimetics are administered, although pressor responses may
be more pronounced with an indirect-acting drug such as ephedrine
What dose of Epi would be safe to use in the concurrent use of TCA’s?
1:100,000
1:10,000
1:1,000
Safer to avoid epi altogether
safer to avoid epi altogether
True about Buspirone
does not produce dependence
Risperidone is associated with
exaggerated hypotension during spinal anesthesia
LA must attach to the _____ channel when it is in the _____ state.
Sodium
Inactivated
Most influential factor affecting duration of LA?
protein binding
Patient in pre-op has been on cisplatin therapy. What is the most important lab?
Mg
Patient taking methotrexate. Rescue Technique includes:
Folate
Thymidine
Normal cells can be protected from lethal damage by folate antagonists with sequential administration of folinic acid (leucovorin), thymidine, or both.
This approach has been termed the rescue technique.
A patient is taking bleomycin, what other considerations would you have other than pulmonary fibrosis?
a. intubation
**
Anthracycline antibiotics (or Doxorubicin) cause (choose 2):
- Cardiotoxicity / cardiomyopathy
2. myelosuppression
A patient on cisplatin therapy, what would be the BEST option for pre-op considerations/labs:
Chem to include BUN/Crt, CBC
First signs of pulmonary toxicity with bleomycin (choose 2):
- basilar rales
- cough
“The first signs of pulmonary toxicity are cough, dyspnea, and basilar rales, which progress in one of two directions.
A mild form of pulmonary toxicity is characterized by exertional dyspnea and a normal resting Pao2.
A more severe form of arterial hypoxemia at rest is associated with radiographic fi dings of interstitial pneumonitis and fibrosis.”
A patient currently being treated with Lithium that has WPW. What would you notice on the EKG?
pacer spikes
what long acting inhaled anticholinergic would you expect your patient with COPD to be taking?
Tiotropium
NMDA receptor antagonist and also binds to opioid receptors and muscarinic receptors. Can be attenuated or abolished with premedicants such as droperidol, Dexmedetomidine, or benzodiazepines:
Ketamine
The mechanism of action of ketamine
is not fully elucidated. It is an N-methyl-d-aspartic acid (NMDA) receptor antagonist and also binds to opioid receptors and muscarinic receptors.
The hemodynamic effects of a bolus of ketamine can be attenuated or abolished with premedicants such as droperidol,
dexmedetomidine, or benzodiazepines
Effect of etomidate on patient undergoing cardiac catherization w/o prior history of PHTN.
No significant hemodynamic changes
Which of the following can be administered IV?
Albuterol
Terbutaline can be given orally, subcutaneously, or intravenously, albuterol (salbutamol) can be given intravenously, and epinephrine is usually given subcutaneously or intravenously. Regardless of the route of administration, all three will produce bronchodilation.
Mechanism of muscarinic receptors that mediate bronchoconstriction and mucous production
Acetylcholine binds to the M3 and M1 receptors and causes smooth muscle contraction via increases in cyclic guanosine monophosphate (cGMP).
” Muscarinic 1 (M1) and muscarinic 3 (M3) receptors are responsible for bronchoconstriction and mucus
production and are the targets of
inhaled anticholinergic therapy. Acetylcholine binds to the M3 and M1 receptors and causes smooth muscle contraction via increases in cyclic guanosine monophosphate (cGMP) or by activation of a G protein (Gq).”
What medication has been used successfully to wean NO in PHTN?
Magnesium
“It has been used successfully to wean
NO in PHTN………. Magnesium has been used to treat persistent PHTN of the newborn, but controversy surrounds its use.”
What levels need to be monitored when NO is administered for more than 24 hours?
Methemoglobin
Patient with bradycardia was treated with the first dose of atropine, bradycardia worsened after second dose bradycardia resolved. What is the reason?
Subtherapeutic dose of atropine was given.
this is used as part of a catecholamine suppression test in the diagnosis of pheochromocytoma.
Clonidine
Patient with hypotension was treated with phenylephrine, hypotension resolved but bradycardia ensued. Explain the cause:
due to stimulation of the baroreceptors
Which of the following has the greatest uptake by the lungs?
Options were histamine, epi, serotonin, norepi, dopamine.
Serotonin
Serotonin 5-ht 90% or great uptake by the lungs. Flood p 602
Norepinephrine demonstrates a 35%
to 50% first-pass uptake with subsequent metabolism by COMT, MAO, aldehyde
reductase, and aldehyde
dehydrogenase.
However, dopamine, isoproterenol, and epinephrine have essentially no uptake.
Histamine, in contrast to 5-HT, has almost
no uptake in the pulmonary circulation
Thoracic epidural anesthesia can have an indirect effect on O2 if _____ or ______ is allowed.
Hypotension
Fall in CO
“TEA may decrease PAP through decreases outflow. in CO or via attenuation of the pulmonary sympathetic TEA depresses right ventricular function in acute PHTN. Unilateral thoracic paravertebral block with lidocaine has been shown to decrease myocardial contractility up to 30% and significantly decrease systemic pressure; an effect that may be attenuated by epinephrine.
In general, the potential benefits of regional anesthesia in thoracoabdominal surgery typically outweigh the risks of
hypotension and right ventricular dysfunction.”
In general, when more than ____ of sodium nitroprusside is administered faster than ____. Cyanide is generated fasters than then patient can eliminate it.
500mcg/kg & 2mcg/kg/min
” most adults can detoxify approximately 50 mg of SNP using existing sulfur stores…..
SNP infusion rates of greater than 2 mcg/kg/minute
IV result in dose- dependent accumulation of cyanide and the risk of
cyanide toxicity must be considered”
True statements regarding Nipride:
Decreased preload, decreased afterload, decreased filling pressures, increased SV, Increased CO
On emergence pt is waking up slowly - pre-op on a lot of meds: atenolol, lantus, CCB… what Lab would you check immediately post op?
Blood Sugar
End products of the cox 2 pathway (and associated effect)
Thromboxane A2 causes Bronchoconstriction
“The final products of these pathways typically have opposed or balancing effects locally and regionally.
Prostaglandin E2 (PGE2) and PGI2 are bronchodilators, for example,
whereas PGF2a, PGD2, and thromboxane A2 (TXA2) cause bronchoconstriction**.
Similarly, PGD2, PGE2, PGF2a, and TXA2 are potent vasoconstrictors, whereas PGE1 and PGF2 are vasodilators.”
Nitroglycerin can also be used for controlled hypotension but is not as effective as an infusion of?? why?
Nitroglycerin exerts its main effect on venous capacitance, any decrease in blood pressure is more volume dependent when compared with sodium nitroprusside - induced hypotension.
“Nitroglycerin is an organic nitrate that acts principally
on venous capacitance vessels and large coronary arteries to produce peripheral pooling of blood and decreased
cardiac ventricular wall tension”
Norepinephrine causes minimal chronotropic effects at low doses due to what? (choose 2)
- Increase in SVR
2. Reflex vagal activity
Beta blocker causes _____ and _____.
Lungs =
Eyes =
lungs - bronchoconstriction
eyes - decrease in intraocular pressure
Tyrosine hydroxylase is used as an add-on drug to the alpha and beta blockers for control of blood pressing patient with
pheochromocytoma
a patient is noted to have an increased PIP and increased wheezing/turbulence on auscultation. What is the MOA of the drug used to control this issue?
Beta 2 agonist: Albuterol = cAMP causing smooth muscle relaxation
tolerance of beta 2 adrenergic agonist is likely due to
down regulation of beta 2 receptors
A patient abruptly stopped taking their Beta 2 agonist. You know that withdrawal of a beta 2 agonist can cause:
Transient bronchial hyperresponsiveness
Scenario with vasoplegic syndrome. first line of treatment is:
0.5 to 1.0 unit bolus of vasopressin followed by an infusion of 0.03 units/min
Which medication is contraindicated with pt on digoxin?
Calcium
“Calcium administration is contraindicated in digoxin treated patients because it may lead to cardiac arrest”
How is nitroglycerin typically mixed?
50mg in 250ml of D5W
a PDE 3 inhibitor:
Milrinone
The ideal pulmonary vasodilator should have…
Rapid Onset of action,
short half life,
and produce regional pulmonary vasodilation
Which of the following is an intermediate risk stratification for surgery?
Prostate surgery (Box 13-3 nagelhout)
High Risk (Reported cardiac Risk Often Greater Than 5%):
• Aortic and other major vascular surgery
• Peripheral vascular surgery
Intermediate Risk (Reported Cardiac Risk Generally 1% to 5%)
• Carotid endarterectomy
• Head and neck surgery
• Intraperitoneal and intrathoracic surgery
• Orthopedic surgery
• Prostate surgery
Low Risk (Reported Cardiac Risk Generally Less Than 1%)† • Endoscopic procedures • Superficial procedures • Cataract surgery • Breast surgery • Ambulatory surgery
Pulmonary artery pressure equation =
PAP = (PVR x CO) + LAP
All are typically utilized in the treatment of PHTN EXCEPT:
Limit Fluids
iNO and prostaglandins have been shown to affect PLT function. Lab to draw?
Bleeding time?
Volatile anesthetics induce bronchodilation by affecting what voltage gated channel?
Calcium
T-type voltage-dependent calcium channel
Three systems involved in vasoplegic syndrome include (select 3)
All are involved EXCEPT: Answer: parasympathetic nervous system
a. Sympathetic system
b. Vasopressin system
c. Renin-angiotensin system
10 mins after the last dose of hydralazine BP is still high. what should you do?
wait - slow onset.
“It is important to remember that the onset of action can occur from 2 to 20 minutes after administration; therefore, adequate time should be allowed before the initiation of repeat dosing so that profound decreases in blood pressure can be prevented.”
Vasoplegic syndrome is due to alterations in SNS, Vasopressin system and
Renin Angiotensin system
Volatile anesthetics produce bronchodilation except:
Desflurane
“Volatile anesthetics reduce bronchomotor tone and all commonly used volatile anesthetics (Table 25-3), except desflurane, produce a degree of bronchodilatation that may be helpful in patients with obstructive lung disease or in patients that experience any degree of bronchoconstriction”
Vasoplegic syndrome can be seen in all surgeries, especially in which of the following?
Cardiac Surgery
Theophylline is seen to have side effects when the blood levels are :
> 20mg/L
Patient received hydralazine at 8am; until what time will the vasodilation effect last?
12hrs –> 8PM
Vasoplegic syndrome is:
Refractory HYPOtension under general anesthesia
Thiopental is thought to have what benefit in cardiac surgery?
Cerebral protection
A patient is prescribed ___, ___, ____. They have recently been prescribed albuterol and have taken it every day since. Lab values: 140, hyperglycemia (200s), hypokalemia (2.5) and hypomagnesium. Which medication would you contribute to the abnormal values?
Albuterol
How long should a patient remain on dual therapy after MI?
up to 6 months
Aspirin is recommended as a lifelong therapy that should never be interrupted for patients with cardiovascular disease. The abrupt withdrawal of aspirin can cause a platelet rebound phenomenon and prothrombotic state leading to major adverse cardiovascular event.
Clopidogrel therapy is mandatory for 6 weeks after placement of bare-metal stents, 3 to 6 months after myocardial infarction, and at least 12 months after placement of drug-eluting stents
Have the most affect on HPV; greatest to least:
Halothane > Enflurane > Iso/Des/Sevo
Not sure where propofol fits in between? IV anesthetics have no effect on HPV)
From greatest to least, volatile anesthetics lower the arrhythmogenic threshold for epinephrine in what order?
Halothane > Enflurane > Sevo =Iso = Des
“hold the epi so i die”
Which medication requires an EKG prior to use according to FDA standards
Droperidol
First sign of Digoxin toxicity under GA?
PVC’s
Beta adrenergic agonists delivered via aerosol exert direct effect on bronchial smooth muscle with few systemic effects. This would be an example of _____.
Direct
Which of the following is true regarding inhaled anticholinergics?
they are poorly absorbed
During the preop eval of your 18 yr old pt scheduled for a tonsillectomy, he begins to complain of short of breath; O2sat 88%. you check a pulse and detect a rate >100bpm. you order a stat EKG; it reveals a rate of 183, a delta wave is present, and it appears to be an atrial tachycardia with an irregular rate. What med would the astute SRNA know to administer to control the rate?
diltiazem
Your first case for the day is an 88-year-old female undergoing nephrectomy. Upon assessment in the preoperative setting you note that her HR is 111, BP 182/88, O2 saturation on RA is 99%, and Respirations are 18. You ask her if she took any meds this morning and she states that she has not taken any medications in the last two days (48 hours ago). You see on her chart that she typically takes Pindolol 20mg/day. She tells you that she could not remember if she was supposed to take her meds before her surgery or not and did not want to bother anyone by asking, she has been on Heart medication for years and thought her heart was fine without it for surgery. You ask her if she takes any medication for HTN because you do not see one listed on her chart and she states no. Which answer below is the most likely reason for the patient’s vital signs?
The patient is having withdrawal symptoms from abrupt discontinuation of her Pindolol
John, a 42 year old that was found down, unresponsive at home, was intubated in the field, is suspected of having gram-negative sepsis. A central line was placed in the ED and the appropriate amount of fluid for resuscitation per sepsis protocol has been administered. His Vital signs are: HR102, O2 saturation 90% on 70% Fio2 and 5 of peep, BP remains 73/41 mmHg. EKG reads Sinus Tach. With occasional PVCs, and PAC’s. The astute SRNA knows the possibility of many interventions, what is the BEST intervention and reason behind that choice?
Norepinephrine infusion for BP ; reason: first line of therapy for shock - mainly alpha - does not depend as much on sensitivity of Beta Receptors
Mr. Sanchez is a 56 y/o male being brought to the OR for an I&D of his infected right foot. After reviewing his medication list, you notice he is taking lisinopril 40mg, HCTZ 10 mg, and amlodipine 5 mg to control his blood pressure. After general anesthesia induction, your blood pressure reading shows 60/40 (map of 42), HR 86, SVR-400, and cardiac index of 3.0. A 500 ml fluid challenge is administered with multiple 100 mcg iv pushes of phenylephrine and 20 mg of iv ephedrine. After 3 minutes, the blood pressure and hemodynamics remain the same. You suspect vasoplegic syndrome. Which of the following drugs will be the MOST appropriate treatment to help improve your patient hemodynamic profile?
Vasopressin 0.5-1 unit IV push followed by a vasopressin drip
A 34 year old female presents to the ER with complaints of chest pain. Her history consists of DM type II, essential hypertension, a recent MI, and recent changes to her medications. Her EKG reveals NSR and her cardiac enzymes are negative. Upon assessment, the astute RRNA discovers the patient has been coughing for the last several days which is the cause of her CP. What is the MOST likely reason for her new onset cough?
Lisinopril
A pregnant patient who is in the second trimester comes in to the ED for irregular spotting and bleeding. The patient states that she is not in pain, but that she wants to get checked out to make sure her baby is safe. Her vital signs are as follows: BP: 190/99, HR 60, RR 16, O2 100%, Temperature 98.6F. The astute SRNA knows that which medication would be best to treat the parturients high blood pressure?
IV Hydralazine 2.5-20mg
Reynold number associated with TURBULENT flow:
> 4,000
Sodium Nitrite 3% is used to promote the production of
methemoglobinemia
