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Spring 2024 > PharmExamIV > Flashcards

PharmExamIV Flashcards

1
Q

What is the other name for neuromuscular monitoring?

A

Acceleromyography

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2
Q

The most common location, nerve, and muscle monitored are?

A

hand, ulnar nerve, adductor policis

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3
Q

What are the long acting NDNMBs?

A

Pancuronium

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4
Q

What are the intermediate acting NDNMBs?

A
  1. Rocuronium
  2. Vecuronium
  3. Cisatracurium
  4. Atracurium
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5
Q

What are the short acting NDNMBs?

A

Mivacurium

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6
Q

What two reversal agents are normally paired together?

A

Neostigmine and Glycopyrolate

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7
Q

What is the mechanism of action for AChE inhibitors?

A

Inhibit acetylcholine esterase at the NMJ, so that ACh can bind and cause muscle contraction.

Competitive antagonists

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8
Q

What subunits do ACh bind to?

A

Alpha

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9
Q

What locations do NMBD reversal agents work at?

A

Preganglionic (SNS & PNS)
NMJ (primary)

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10
Q

What is the ceiling effect?

A

The point at which the drug will no longer have any effect

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11
Q

What is the max dose of neostigmine?

A

5 mg

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12
Q

What is the max dose of Edrophonium

A

1 mg/kg

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13
Q

How many twitches do we need to see before we can reverse?

A

1-2 twitches. Muscular blockage cannot be reversed if there are 0 twitches.

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14
Q

What are the 5 factors that influence the reversal of NMB?

A
  1. Depth of block
  2. AChE inhibitor choice
  3. Dose administered
  4. Rate of plasma clearance
  5. Anesthesia agent choice and depth

–> Postoperative residual NM blockade

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15
Q

What is the dose range of neostigmine?

A

0.04-0.07 mg/kg

OR

40-70 mcg/kg

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16
Q

What’s important to note regarding paralytics and their reversal agents?

A

The paralytics can last longer than the reversal agents.

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17
Q

What is the onset time of neostigmine?

A

5-10 minutes

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18
Q

What is the duration of action for neostigmine?

A

60 minutes

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19
Q

How is glycopyrolate dosed with neostigmine?

A

0.2 mg per mg of neostigmine

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20
Q

What is the dose for sugammadex?

A

2-16 mg/kg

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21
Q

What is the onset time of sugammadex?

A

1-4 minutes

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22
Q

What is the duration of sugammadex?

A

1.5-3 hours

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23
Q

What is the dose for succinylcholine (Anectine)?

A

1-1.5 mg/kg

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24
Q

What is the onset of succiynlcholine (Anectine)?

A

30-60 seconds

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25
Q

What is the duration of action for succinylcholine (Anectine)?

A

5-10 minutes

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26
Q

What is the dose for pancuronium (Pavulon)?

A

0.1 mg/kg

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27
Q

What is the onset for pancuronium (Pavulon)?

A

2-3 minutes

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28
Q

What is the duration of pancuronium (Pavulon)?

A

60-120 minutes

or

1-2 hours

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29
Q

What is the dose for cisatracurium (Nimbex)?

A

0.1 mg/kg

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30
Q

What is the onset for cisatracurium (Nimbex)?

A

2-3 minutes

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31
Q

What is the duration for cisatracurium (Nimbex)?

A

40-75 minutes

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32
Q

What is the dose for vecuronium (Norcuron)?

A

0.1 mg/kg

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33
Q

What is the duration for vecuronium (Norcuron)?

A

45-90 minutes

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34
Q

What is the onset for vecuronium (Norcuron)?

A

2-3 minutes

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35
Q

What is the dose of edrophonium?

A

0.5 to 1 mg/kg

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36
Q

What is the onset of edrophonium?

A

1 to 2 minutes

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37
Q

What is recurarization?

A

An increase in neuromuscular block after a variable period of recovery.

Patient becomes paralyzed again

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38
Q

If our dosage was 50mcg/kg

How much neostigmine will you administer in mL for a 100kg patient?

Neostigmine is available at 1 mg/mL

A
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39
Q

What is the renal excretion of the NMBD reversal agents?

Neo, Pyrido, and Edroph

A

Neo is 50%
Pyrido and Edrop are 75%

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40
Q

What does CRF do to plasma clearance? How does this affect our reversal agents?

A

Renal failure decreases plasma clearance and increases the duration of action.

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41
Q

What are the primary side effects of NMBD reversal drugs?

A

Increased nicotinic/muscarinic activty
CV: brady, asystole, arrythmia
Pulm: bronchoconstriction, salivation
GI: PONV, gastric fluid secretion
Eyes: Miosis

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42
Q

What reversal agent is preferred for cardiac disease?

A

Glycopyrrolate

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43
Q

What anti-cholinergic/anti-muscarinic is given to prevent side effects with Edrophonium?

A

Atropine: 7-10 mcg/kg

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44
Q

What anti-cholinergic/anti-muscarine is given to prevent side effects with neostigmine and pyridostigmine??

A

Glycopyrrolate

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45
Q

10 mcg/kg is the dose for this patient

How much neostigmine will you administer in mL for a 100kg patient?

Neostigmine is available at 0.2 mg/mL

A
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46
Q

What is the mechanism for persistent NM blockade?

A

Acetylcholinesterase is maximally inhibited and no further anticholinesterase is effective

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47
Q

What is the MoA of sugammadex (Bridion)?

A

Encapsulates and binds the NMBD molecules
Binds to free drug in the plasma (not proteins)
Forms a concentration gradient using hydrophobic interactions

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48
Q

What is the elimination 1/2 time of Sugammadex (Bridion)?

A

2 hours

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49
Q

What is the major route of elimination for sugammadex (Bridion)?

A

Urine

70% in 6 hours
90 % in 24 hours

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50
Q

How are neostigimine and edrophonium cleared if renal function is impaired?

A

30-50% hepatic clearance

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51
Q

What type of molecule is sugammadex (Bridion)? What are its properties?

A

γ-cyclodextrin
dextrose units from starch
Highly water soluble

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52
Q

What are dose related sugammadex (Bridion) side effects?

A

N/V
Pruritis
Urticaria

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53
Q

How do you readminister roc or vec after reversal (up to 4mg/kg bridion)?

A

Wait 5 minutes and then administer 1.2 mg/kg rocuronium

If NMB is req before recommended waiting time, use nonsteroidal NMBD

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54
Q

What are some contraindications for sugammadex?

A
  1. Oral contraceptives
  2. Toremifene (no-steroidal anti-estrogen) - displaces NMBD from sugammadex
  3. Heparin - Coagulopathy/Bleeding
  4. Less than recommended doses - Recurarization
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55
Q

What are the s/s of recurarization?

A
  1. Can verbalize - suffocating feeling
  2. Unable to sustain head lift or hand grasp
  3. Pharyngeal collapse and respiratory obstruction
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56
Q

How do we treat recurarization?

A
  1. Re-sedate patient
  2. Give additional reversal agents in divided doses (Neo 0.05 mg/kg IV = longer DoA)
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57
Q

What is the clinical duration of response for pancuronium?

A

86 minutes

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58
Q

What is the clinical duration of response for rocuronium?

A

36 minutes

Rocky is 36 minutes late

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59
Q

What is the clinical duration of response for vecuronium (Norcuron)?

A

44 minutes

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60
Q

What is the clinical duration of response for atracurium?

A

46 minutes

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61
Q

What is the clinical duration of response for cisatracurium (Nimbex)?

A

45 minutes

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62
Q

What is the clinical duration of response for mivacurium?

A

16.8 minutes

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63
Q

What preservative is found in both esters and amides that can cause allergies?

A

Methylparaben

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64
Q

What are the S/S of IgE anaphylaxis?

A

Rash
Urticaria
Laryngeal edema
hypotension
bronchospasm

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65
Q

What is LAST?

A

Local Anesthetic Systemic Toxicity
Results from an excess plasma concentration of the drug

Entrance into the systemic circulation

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66
Q

What does LAST depend on?

A

Dose
Vascularity of site
Epinephrine
Physiochemical properties

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67
Q

What is the order of the blood concentration at LA injection sites from the highest to the lowest?

A
  1. IV
  2. Tracheal
  3. Caudal
  4. Paracervical
  5. Epidural
  6. Brachial
  7. Sciatic
  8. Subcutaneous

ITCPEBSS

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68
Q

What is the dose dependent effect of Lidocane at 1-5 mcg/mL?

A

Analgesia

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69
Q

What is the dose dependent effect of Lidocane at 10-15 mcg/mL?

A

Seizures
Unconciousness

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70
Q

What is the dose dependent effect of Lidocane at 15-25 mcg/mL?

A

Apnea
Coma

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71
Q

What is the dose dependent effect of Lidocane at >25 mcg/mL?

A

cardiovascular depression

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72
Q

What is the dose dependent effect of Lidocane at 5-10 mcg/mL?

most effects…

A

Circumoral numbness
Tinnitus
Skeletal muscle twitching
Hypotension
Myocardial depression

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73
Q

How does lidocaine cause cardiovascular affects?

A

Block cardiac Na+ channels
Slows conduction of cardiac impulses
Prolongs PR interval & causes QRS widening

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74
Q

Which local anesthetic causes the worst cardiovascular system effects?

A

Bupivacaine

Latches onto cardiac muscle?

Bupivacaine > Ropivacaine > Lidocaine

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75
Q

What two factors predispose our OB population to local anesthetic toxicity?

A
  1. Decreased plasma esterases
  2. Decreased plasma proteins
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76
Q

What are the 3 goals of LAST treatment?

A
  1. Prompt airway management
  2. Circulatory support
  3. Removal of LA from receptor sites
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77
Q

What drugs are used to treat LAST?

There are several

A

100% oxygen
Barbituates
Benzodiazepines
Epinephrine
Propofol
Muscle Relaxants
Intralipid

Medications given depends on the symptoms seen

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78
Q

What is intralipid? What is the MoA?

A

Intralipid is lipid emulsion therapy that creates a lipid compartment. The lipid emulsion acts as a “sink” for the lipophilic (fat-soluble) local anesthetic molecules. The local anesthetic molecules diffuse from the tissues and plasma into the lipid phase of the emulsion, reducing their concentration in the bloodstream and tissues.

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79
Q

If the patient does not respond to intralipid, what is the next step?

A

CPB/ECMO

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80
Q

What is the dose for intralipid?

A

1.5 mL/kg of 20% lipid emulsion
0.25 mL/kg/minute infusion for at least 10 minutes

Max dose: 3.8 mL/kg (1.2 to 6 mL/kg) in 30 minutes

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81
Q
A

16,200 mgs

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82
Q

What are the 3 categories of neural tissue toxicity from LAs?

A
  1. Transient Neurological Symptoms (TNS)
  2. Cauda Equina Syndrome
  3. Anterior Spinal Artery Syndrome

Either transient or permanent neurological injury

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83
Q

What are transient neurological symptoms?

A

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

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84
Q

What is the treatment for transient neurological symptoms?

A
  1. Trigger point injections
  2. NSAIDS
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85
Q

What is cauda equina syndrome?

A

Diffuse injury at the lumbosacral plexus

Varying degrees of: sensory anesthesia, bowel and bladder dysfunction, & paraplegia

Associated w: disc hernation, prolapse, or sequest w urinary retention

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86
Q

What is anterior spinal artery syndrome?

A

Lower extremity paresis with a variable sensory deficit

The cause is uncertain. It could be a thrombosis or a spasm of the bilateral anterior spinal artery.

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87
Q

Which LAs can cause methemoglobinemia?

A

Prilocaine > benzocaine > lidocaine

Nitroglycerine, phenytoin, and sulfonamides also cause metHgb

Pril, Benny, and Liddy met

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88
Q

What is the dosage for methylene blue?

A

1 mg/kg over 5 mintutes (max 7 to 8 mg/kg)

Reversal from ferric Hgb to ferous Hgb is within 20-60 minutes

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89
Q

What are CO2 retainers susceptible to?

A

Lidocaine depressing the ventilatory response to arterial hypoxemia

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90
Q

What is the primary cause of hepatotoxicity with LAs?

A

Continuous or intermittent epidural bupivacaine to treat posthereptic neuralgia. Stop the infusion.

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91
Q

What is the MoA of cocaine toxicity?

A

SNS stimulation by blocking presynaptic uptake of NE and dopamine

Increases postsynaptic levels

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92
Q

What are the adverse effects of cocaine toxicity?

A

HTN
Tachycardia
Coronary vasospasm
MI
Ventricular dysrythmias
Fetal hypoxemia
Seizures

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93
Q

What are the 4 antiarrythmic drug classes?

A

Class I - Sodium-channel blockers.
Class II- Beta-blockers.
Class III- Potassium-channel blockers.
Class IV- Calcium-channel blockers.

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94
Q

What is the IV dosage of lidocaine?

A

1 to 2 mg/kg IV (initial bolus) over 2-4 minutes
1 to 2 mg/kg/hour (drip) terminated 12-72 hours

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95
Q

What is the easy way to remember what class a LA belongs to?

A

One “i” in the name means that it is an ester anesthetic (Cocaine)
More than one “i” it is an amide (Lidocaine)

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96
Q

What is the molecular structure of lidocaine?

A

Lipophilic portion (1) connected by a hydrocarbon chain (2) to the hydrophillic portion (3).

The bond between (1) and (2) classifies it as an ester or an amide

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97
Q

What determines whether or not a local anesthetic is a amide or an ester?

A

The intermediate chain

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98
Q

What is the pH of local anesthetics?

A

6

Weak bases

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99
Q

What four LAs have a potency of 1?

A
  1. Procaine
  2. Lidocaine
  3. Prilocaine
  4. Mepivicaine

Roc, Doc, & Loc me in as #1

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100
Q

What LAs have a potency of 4?

Hint: there are 4

A
  1. Chloroprocaine (Rapid)
  2. Bupivacaine (Slow)
  3. Levobupivacine (Slow)
  4. Ropivacaine (Slow)

Chlorbupriva came in 4th

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101
Q

Which two LAs have a rapid onset?

A

Chloroprocaine
Lidocaine

THE REST OF THE LAs ARE SLOW ONSET

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102
Q

Which local anesthetic is odd man out in terms of potency?

A

Tetracaine (16!)

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103
Q

What 3 LAs have a duration of 240-480 minutes?

A
  1. Bupivacaine
  2. Levobupivacaine
  3. Ropivacaine

It’s too far for Mepiva to come here

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104
Q

Which LA has the shortest duration time?

A

Chloroprocaine
30-45 minutes

Rapid, Potency of 4

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105
Q

Which LA has the 2nd shortest duration?

A

Procaine
45-60 minutes

potency 1, onset slow

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106
Q

Which anesthetics have durations between 60 and 180 minutes?

Hint: There are 4.

A

Lidocaine (60-120 min)
Prilocaine (60-120 min)
Tetracaine (60-180 min)
Mepivacaine (90 -180 min)

For the next 60-180 min, I’m your life pilot, tip me!

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107
Q

Which LAs do not have an toxic plasma concentration?

A

Ester LAs

Ester is not a toxic bitch

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108
Q

What are the pKs of the ester anesthetics? What are they?

A

Procaine (pK = 8.9)
Chloroprocaine (pK = 8.7)
Tetracaine (pK = 8.5)

Each pK drops by 0.2! (PCT!!)

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109
Q

Which LAs have a pK in the range of 7?

A

Lidocaine (pK = 7.9)
Prilocaine (pK = 7.9)
Mepivacaine (pK = 7.6)

Li, Pri, and Me are on the 7th floor.

110
Q

Which LAs all have an pK of 8.1?

A
  1. Bupivacaine
  2. Levobupivacaine
  3. Ropivacaine

pK = 8.1

Bu, Lev, Ro can park on 8, except Mepiva, cuz she’s a bitch

111
Q

What are the properties of nonionized drugs?

A

Faster onset of action
More lipid soluble
Works better

112
Q

What do liposomes do?

A

Prolongs duration of action and decreases toxicity of LAs

Liposomal drug delivery improves the therapeutic efficacy of drugs, reduces side effects, and prolongs drug circulation time in the body.

113
Q

What is the MoA of LAs?

A

Binds to VG-Na+ channels
Blocks/inhibits Na+ in nerve membranes

114
Q

What 3 factors affect motor blockade?

A
  1. Lipid solubility
  2. Repetitively stimulated nerve
  3. Diameter of the nerve
115
Q

What are other target action sites of LAs besides VG-Na+ channels?

A
  1. K+ channels
  2. Ca2+ channels
  3. GPCRs
116
Q

What is MEC?

A

Minimum Effective Concentration
Similar to MAC for VAs, but for LAs

117
Q

How many nodes of ranvier do we need to block?

A

At least 2, preferably 3 (1 cm)

118
Q

Which nerve fibers are blocked first by a LAs?

A

Myelinated preganglionic B fibers (SNS)

119
Q

What nerve fibers are second to be blocked by LAs?

A

Small and medium sized myelinated A and B

120
Q

What determines a LA’s intrinsic vasodilator activity?

A

Potency and DoA

Lidocaine = greater systemic absorption

121
Q

What effect does the pKa being closer to physiologic pH have on LAs?

A

More rapid onset

122
Q

What percentage of LAs are lipid soluble in nonionized form?

A

50%

LAs are weak bases with pKa values above physiologic pH

123
Q

What does adding epi to our LAs do?

A

Increases duration of action

124
Q

What is the primary determinant of potency?

A

Lipid solubility

125
Q

The rate of clearance for LAs depends on what two factors?

A
  1. Cardiac Output
  2. Protein binding: % bound is inversely related to % plasma
126
Q

How are esters metabolized?

A

Hydrolysis by cholinesterase enzyme in plasma

Except cocaine by the liver

127
Q

What is the primary metabolite of an ester LA?

A

Para-aminobenzoic acid (PABA)

128
Q

How are amides metabolized?

A

Microsomal enzymes in the liver

  1. Most rapid: Prilocaine (Primary)
  2. Intermediate: Lidocaine & Mepivacaine (IdMediate)
  3. Slowest: Etidocaine, bupivacaine & ropivacaine (ERB)
129
Q

What two things need to be kept in mind with pregnant patients?

A

Lower levels of cholinesterases
Significant transplacental transfer (Ion trapping)

mostly occurs with amides

130
Q

Which LAs undergo first pass pulmonary extraction?

A

Lidocaine
Bupivacaine
Prilocaine

LiBuri

131
Q

Which LA is most protein bound? Least?

A
  1. Bupivacaine (95%)
  2. Lidocane (70%)
  3. Prilocaine (55%)

Protein binding and arterial concentration are inversely related

Protein Butt Lipper

132
Q

What is the maximum infiltration dose of lidocaine?

A

300 mgs plain and 500 mgs with Epi

133
Q

What is the metabolite of lidocaine?

A

Xylidide

134
Q

How is lidocaine metabolized?

A

Oxidative dealkylation in the liver, then hydrolysis

135
Q

What is the metabolite of prilocaine? What’s important to note about it?

A

Orthotoluidine

Converts Hgb into metHgb

136
Q

What LA is this?

Similar to Lidocaine, except with:
Longer duration of action
Lacks vasodilator activity
Prolonged elimination in fetus & newborn; no OB

A

Mepivacaine

137
Q

What LA is this?

Metabolism: aromatic hydroxylation, N-dealkylation, amide hydrolysis, and conjugation
Protein (95%) binding site: α1-Acid glycoprotein

A

Bupivacaine

138
Q

What LA is this?

Metabolism: Liver
MOA: inhibits the activity of normal butyrylcholinesterase (plasma cholinesterase) by more than 70%

A

Dibucaine

138
Q

What LA is this?

Metabolism: Hepatic cytochrome P450 enzymes
Metabolites: can accumulate with uremic patients
Lesser system toxicity than Bupivacaine
Protein Binding: α1-acid glycoprotein

A

Ropivacaine

139
Q

What LA is this?

Metabolism: Plasma cholinesterase (3.5x faster)
Pregnancy decreases plasma cholinesterase by 40%

A

Chloroprocaine

140
Q

What LA is this?

Metabolite: PABA, excreted unchanged in urine

A

Procaine

141
Q

What LA is this?

Metabolism: Slower than procaine

A

Tetracaine

142
Q

What LA is this?

Unique: Weak acid (pKa 3.5)
Uses: Topical anesthesia of mucous membranes:
Tracheal intubation, Endoscopy, Transesophageal echocardiography (TEE), Bronchoscopy
Onset: rapid
Duration: 30 to 60 minutes
Dose: Brief spray (20%) = 200 to 300 mgs
Methemoglobinemia

A

Benzocaine

143
Q

What LA is this?

Metabolism: Plasma and liver cholinesterases
Decreased in: Parturients, Neonates, Elderly, Severe Hepatic Disease
Peak: 30 to 45 mins
Duration: 60 minutes after peak
Elimination: Urine (24 to 36 hours)
Caution: Coronary vasospasm, ventricular dysrhythmias, HTN, tachycardia, CAD

A

Cocaine

144
Q

What is the maximum dose of methylene blue in mgs for a 120 lbs patient?

Divide by 2, subtract 10% for lbs to kg

A
145
Q

What does alkalinization of LAs do?

A

Increases % of lipid soluble or non-ionized form
Enhances depth
Increases spread
Faster onset

146
Q

What LA adjuvant is this?

Increased duration of:
Both motor and sensory blocks
First analgesic request after spinal anesthesia

A

Dexmedetomidine

147
Q

What LA adjuvant is this?

Increased duration with subarachnoid block with or without opioids.

A

Magnesium

148
Q

What LA adjuvant is this?

Prolongs pediatric regional anesthesia duration.

A

Clonidine & Ketamine

149
Q

What LA adjuvant is this?

Increased duration either IV or mixed with LA.

A

Dexamethasone

150
Q

The __________ of a LA is _________ to the time the drug is in contact with nerve fibers

A

DoA; Proportional

151
Q

Toxic effects are _______

A

additive

152
Q

Epinephrine as an additive

1:200,000

A

1,000,000 / 200,000

5 mcg/mL

153
Q

Epinephrine as an additive

1:500,000

A

1,000,000 / 500,000

2 mcg/mL

154
Q

Epinephrine as an additive

1:10,000

A

1,000,000 / 10,000

100 mcg/mL

155
Q

Epinephrine as an additive

1:1,000

A

1,000,000 / 1,000

1000 mcg/mL or 1 mg/mL

156
Q

Local Anesthetic Strengths

0.25%

A

2.5 mgs/mL

157
Q

Local Anesthetic Strengths

0.5%

A

5 mgs/mL

158
Q

Local Anesthetic Strengths

1%

A

10 mgs/mL

159
Q

What is the dose of this anesthetic

2%

A

20 mgs/mL

160
Q

Local Anesthetic Strengths

4%

A

40 mgs/mL

161
Q

What are the total mgs for bupivacaine and the total mcgs for epinephrine if the surgeon injects 20 mLs of 0.25% bupivacaine with 1:200,000 of epi?

A

2.5 mgs/mL bupivacaine x 20 mLs = 50 mgs

5 mcg/mL x 20 mLs = 100 mcg

162
Q

What is the dosage of bupivacaine with and without epi for infiltration, PNB, epidurals, and spinals?

A

175 mg alone or 225 mg with epi

163
Q

What is the dose for lidocaine with or without epi?

A

300 mgs alone or 500 mgs with epi

164
Q

What are the 3 clinical uses for lidocaine with epinephrine?

A
  1. Infiltration
  2. PNB
  3. Epidural
165
Q

What is the dose for lidocaine in a spinal?

A

100 mgs

166
Q

Which three clinical uses for lidocaine is epinephrine not added?

A

Topical, IV regional anesthesia, and Spinals

167
Q

112.5 mgs of bupivacaine with epi and 250 mgs of lidocaine with epi were given during a case. What are the percentages of each local anesthetic based on the recommended maximum single dose in mgs?

A

This is 50% max of both local anesthetics.
50 + 50 = 100
No more can be given.

168
Q

Where can topical anesthesia be applied?

A

Mucus membranes of nose, mouth, tracheobronchial tree, esophagus, or GU tract

169
Q

What is the topical dosage of cocaine, tetracaine, and lidocaine?

A

Cocaine (4% to 10%) > Lidocaine (2% to 4%), Tetracaine (1% to 2%)

Cocaine causes localized vasoconstriction

170
Q

What is the order of effect for peripheral nerve block?

A
  1. Proximal affected first and then distal
  2. Proximal comes back first and then distal
  3. Smallest sensory and ANS fibers first, and then larger motor and proprioceptive axons
171
Q

What’s different about using topical lidocaine over topical cocaine in the tracheobronchial tree?

A

Inhalation of lidocaine does not alter airway resistance, but it does cause vasodilation

172
Q

What’s important to know about transtracheal lidocaine anesthesia?

A

Squirt all of it at once. Do not squirt as you withdraw.

173
Q

What is EMLA?

A

Eutectic Mixture of LA

Lidocaine and Prilocaine 2.5% = 5% LA

Dose 1 to 2 grams/10 cm2 area

Do not use with skin wounds, beware of methemoglobinemia

174
Q

IV injection of a LA into an extremity isolated from the rest of the systemic circulation with a tourniquet

Sensation and muscle tone dependent on tourniquet

A

Bier Block

175
Q

Produced by direct injection of LA into subarachnoid
CSF is confirmation
Preganglionic fibers: Principal site of action
Sensory effect is on same level of denervation

A

Spinal Anesthesia Block

176
Q

SNS is 2 spinal segments ______ of sensory

A

Cephalad

177
Q

Motor is 2 spinal segments below ______

A

sensory

178
Q

How do we dose subarachnoid blocks?

A
  1. Height of patient
  2. Segmental level of anesthesia desired
  3. Duration of anesthesia desired
179
Q

What is important for determining the spread of a local anesthetic in the CSF?

A

Specific gravity

180
Q

_____ is more important than the concentration of the drug or the volume of the solution injected with subarachnoid blocks

A

dose

181
Q

What two drugs are used in tumescent liposuction? What are their doses?

A

Epi and Lido; 1:100,000 that is highly diluted with 35-55 mg/kg of lidocaine tumescent

182
Q

What is the dose for glycopyrrolate?

A

7-15 mcg/kg (1 mg max)

183
Q

What is the onset of NDNMB in order from fastest to slowest?

A
  1. Rocuronium
  2. Vecuronium
  3. Pancuronium
  4. Atracurium
  5. Mivacurium
  6. Cisatracurium

RV Pack All Mi Camping gear

RV pack all my camping gear

184
Q

The closer the pKa is to pH…

A

50:50; Ionized:Nonionized

185
Q

What are the ester anesthetics?

A

Procaine (pK = 8.9)
Chloroprocaine (pK = 8.7)
Cocaine
Benzocaine
Tetracaine (pK = 8.5)

Ester is a PCCT

186
Q

What is the dosage of sugammadex for an extreme block?

A

8 to 16 mg/kg

187
Q

What is the dosage of sugammadex for a deep block?

A

4 mg/kg

188
Q

What is the dosage of sugammadex for a moderate block?

A

2 mg/kg

189
Q

What are the 5 factors influencing NMBD reversal?

A
  1. Intensity of the block
  2. NMBD used
  3. Continued volatile anesthetic
  4. Reversal drug used
  5. Patient conditions (acidotic, hypothermic)
190
Q

What type of bond interactions or forces does sugammadex use?

A
  1. Intermolecular (Van Der Waals) forces
  2. Thermodynamic (Hydrogen) Bonds
  3. Hydrophobic interactions
191
Q

What was the first local anesthetic?

A

Cocaine

192
Q

What were the first synthetic ester and amide anesthetics?

A

Procaine; Lidocaine

193
Q

Which anesthetic is the standard to which all others are compared?

A

Lidocaine

194
Q

What 3 systems are carefully monitored with IV lidocaine?

A
  1. Cardiac
  2. Hepatic
  3. Renal
195
Q

What anesthetics can utilize liposomes?

A
  1. Bupivacaine
  2. Lidocaine
  3. Tetracaine

BLT are fatty

196
Q

What is Exparel?

A

Bupivacaine ER
Liposomes containing bupivacaine
Lasts up to 96 hours

197
Q

What anesthetics do not have a significant amount of transplacental transfer?

A

Esters

198
Q

Which amide(s) are most rapidly metabolized?

A

Prilocaine

199
Q

Which amides are intermediately metabolized?

A
  1. Lidocaine
  2. Mepivacaine

idermediate

200
Q

What amides have the slowest metabolism?

A
  1. Etidocaine
  2. Ropivacaine
  3. Bupivacaine

ERB

201
Q

What is the peak and duration of cocaine?

A

Peak: 30-45 minutes
Duration: 60 minutes after peak

202
Q

What is the average pKa of LAs?

A

8

203
Q

Alkalinization improves the onset of action in peripheral and epidural blocks by how much time?

A

3 to 5 minutes

204
Q

What effect do vasoconstrictors have on the rate of onset for LAs?

A

No effect

205
Q

_______ effects may have some degree of analgesia

A

a-adrenergic

206
Q

What is the purpose of using topical cocaine?

A

Cocaine causes localized vasoconstriction which:
1. Decreases blood loss
2. Improves surgical visualization

207
Q

What is EMLA contraindicated with?

A

Amide allergies

208
Q

Achieved by LA injection into tissues surrounding individual peripheral nerves or nerve plexuses

A

Peripheral Nerve Block

209
Q

What is the MoA for a PNB?

A

Diffusion from the outer mantle to the central core of nerve along a concentration gradient

210
Q

What is the point of a eutectic mixture?

A

Improves the solublity of drugs by combining them

211
Q

How long does it take before you can do skin grafting with a eutectic mixture?

A

2 hours

212
Q

How long does it take before you can do cautery of genital warts, venipicture, lumbar puncture, arterial cannulation, and myringotomy with a eutectic mixture?

A

10 minutes

213
Q

In peripheral nerve blocks…

Duration depends on

A

dose of local anesthetic

214
Q

In peripheral nerve blocks…

onset depends on?

A

pK of the local anesthetic

215
Q

What are the 4 examples of PNBs provided by Castillo?

A
  1. Interscalene
  2. Axiallary
  3. Femoral
  4. Sciatic
216
Q

What LA is most commonly used in a Bier block?

A

Lidocaine

217
Q

What are the steps of a bier block?

A
  1. IV start
  2. Exsanguination
  3. Double cuff
  4. LA injection
  5. IV D/C
218
Q

What is the blockade sequence in neuraxial anesthesia?

A
  1. SNS
  2. Sensory
  3. Motor
219
Q

What confirms a spinal anesthesia block (SAB)?

A

CSF

220
Q

What is the principal site of action for a SAB?

A

Preganglionic fibers

221
Q

What is the most commonly used anesthetic in epidural anesthesia?

A

Lidocaine

222
Q

When will the epidural have an effect on the fetus?

A

24 to 48 hours

223
Q

What is the normal onset of an epidural?

A

15 to 30 minutes

224
Q

What component of the local anesthetic is required for a conduction block?

A

Non-ionized form

225
Q

True or False

In general, the more lipid soluble the local anesthetic is, the greater its potency.

A

True

226
Q

Which local anesthetic property is most important when it comes to duration of action?

A

protein binding

227
Q

What four things can affect duration of action?

A
  1. Protein binding
  2. Lipid solubility
  3. Metabolism
  4. Clearance
228
Q

What is more acceptable as an additive to both epidurals and SABs?

A

Opioids

229
Q

What is one of the differences between epidurals and SAB?

A

No differential zone of SNS

230
Q

In a SAB, 5 ft is equal to _____

A

1 mL

231
Q

In SAB, for every inch above 5ft you add

A

0.1 mL

232
Q

How many people will have an allergic reaction from a LA?

A

Very rare

<1%

233
Q

What anesthetics cause more allergic reactions?

A

Esters

234
Q

What promotes seizures with LAs?

A

Hyperkalemia

235
Q

What is the duration of rocuronium?

A

35 to 75 minutes

236
Q

What peripheral nerves are myelinated?

A

A-a
A-b
A-gamma
A-delta
B

237
Q

What peripheral nerve fibers have a sensitivity of 1 to procaine?

A

A-a
A-b
A-gamma

238
Q

What peripheral nerve fiber is this?

Innervation of skeletal muscles
Proprioception

A

A-alpha

239
Q

What peripheral nerve fiber is this?

Touch
Pressure

A

A-beta

240
Q

What peripheral nerve fiber is this?

Skeletal muscle tone

A

A-gamma

241
Q

What peripheral nerve fiber is this?

Fast pain
Touch
Temperature

A

A-delta

242
Q

What peripheral nerve fiber is this?

Preganglionic autonomic fibers

A

B

243
Q

What peripheral nerve fiber is this?

Slow Pain
Touch
Temperature
Postganglionic sympathetic fibers

A

C

244
Q

What peripheral nerve fiber(s) have a 0.5 sensitivity to procaine?

A

A-delta
C

245
Q

What peripheral nerve fiber(s) have a 0.5 sensitivity to procaine?

A

B

246
Q

What is the duration of action of all the muscle relaxants from shortest to longest?

A
  1. Succinylcholine (5-10 min
  2. Rocuronium (35-75 min)
  3. Cisatracurium (40-75 min)
  4. Vecuronium (45-90 min)
  5. Pancuronium (60-120 min)

SR or MR CVP

247
Q

What are the pKs of Lidocaine, Prilocaine, and Mepivacaine?

A

Lidocaine (pK = 7.9)
Prilocaine (pK = 7.9)
Mepivacaine (pK = 7.6)

248
Q

What anesthetics have pKs above 8?

A

Bupivacaine (pK = 8.1)
Levobupivacaine (pK = 8.1)
Ropivacaine (pK = 8.1)
Procaine (pK = 8.9)
Chloroprocaine (pK = 8.7)
Tetracaine (pK = 8.5)

ALL EXCEPT Li, Pri, & Me

249
Q

What are the pKs of Lidocaine, Prilocaine, and Mepivacaine?

A

Lidocaine (pK = 7.9)
Prilocaine (pK = 7.9)
Mepivacaine (pK = 7.6)

Li, Pri, and Me are on the 7th floor

250
Q

How long does MetHgb reversal take after giving methylene blue?

A

20-60 minutes

251
Q

What’s another possible reversal for mivacurium?

A

Purified human plasma cholinesterase

252
Q

What is toremifene? What’s important to know about it?

A

Non-steroidal anti-estrogen

Can displace NDMB from sugammadex

253
Q

Protein binding is equal to….

A

rate and degree of diffusion

254
Q

How much 8.4% NaHCO3- is added to 30 mL of LA?

A

1 mL

255
Q

Which combination of LAs has a rapid onset and tachyphylaxis

A

Chloroprocaine and Bupivacaine

256
Q

What is the dose for regional anesthesia with lidocaine and epineprhine?

A

7 mg/kg

257
Q

What is the tissue buffering system?

A

1 gm SQ tissue can absorb up to 1 mg of lidocaine

258
Q

What is the plasma peak s/p injection?

A

12-14 hours

259
Q

How much SQ infiltration can occur with tumescent liposuction?

A

5 L

260
Q

Glycopyrrolate is administered slowly over….

A

2-5 minutes

261
Q

Which type of medication is given first during reversal?

A

Anti ACh drug

262
Q

Sugammadex is contraindicated in…

A

patients on dialysis

263
Q

What NMBD are not reversed by sugammadex?

A
  1. Atracurium
  2. Mivacurium
  3. Cisatracurium

AMC

264
Q

How much epinephrine do you give with intralipid therapy?

A

10 to 100 mcg

265
Q

What are the predisposing factors for cardiovascular system effects with LAs?

A
  1. Pregnancy
  2. Arterial hypoxemia
  3. Beta blocker, digitalis, Ca2+ (cardiac drugs)
  4. Epinephrine & Phenylephrine
266
Q

How long is the recovery time from TNS?

A

1 to 7 days

267
Q

What is the order of lipid solubility of lowest to highest?

A
  1. Procaine
  2. Prilocaine
  3. Mepivacaine
  4. Lidocaine
  5. Bupivacine
  6. Tetracaine

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268
Q

What is the order of protein binding (%) from lowest to highest

A
  1. Procaine
  2. Prilocaine
  3. Lidocaine
  4. Tetracaine
  5. Mepivacaine
  6. Ropivacaine
  7. Bupivacaine
  8. Levopbupivacaine

PPL Tell MR B Lies about protein binding

269
Q

What nerve fibers are last to be blocked by LAs?

A

C

270
Q

Which populations have decreased plasma cholinesterases????

A
  1. old people
  2. neonates
  3. pregnant people
  4. severe hepatic disease

Spring 2024 (9 decks)

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