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Anesthesia Pharmacology Review > Preoperative Medications > Flashcards

Preoperative Medications Flashcards

1
Q

rMost preoperative anesthesia medications are given for what reasons?

A

Prevent or limit:
* Aspiration pneumonia
* Bronchospasm

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2
Q

Histamines are endogenous substances that are released from ___ and __.

A

Mast cells
Basophil cells

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3
Q

How does Histamine affect the airway?
The stomach?

A
  • Contraction of smooth muscles
  • Secretion of acid
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4
Q

What neurotransmitters in the CNS are released by Histamine?

A
  • Acetylcholine
  • Norepinephrine
  • Serotonin
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5
Q

What drugs induce the release of histamine?

A
  • Morphine
  • Mivacurium (Mivacron)
  • Protamine
  • Atracurium (Tracrium)
  • Succinylcholine
  • Pancuronium
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6
Q

How do we counteract drug-induced histamine release?

A

Treat with H1 and H2 antagonists

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7
Q

When H1 receptors are activated what become activated?

A
  • Muscarinic
  • Cholinergic
  • 5-HT3
  • ⍺-adrenergic
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8
Q

When H2 receptors are activated what other receptors become activated?

A

5-HT3
β1

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9
Q

What occurs when Histamine binds to an H1 receptor?

A

Hyperalgesia
Inflammatory pain
Allergic rhino-conjuctivitis symptoms

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10
Q

What occurs when Histamine binds to H2 receptors?

A

Elevate cAMP (β1-like stimulation)
Increase acid/volume production

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11
Q

What occurs with H1 and H2 activation?

A
  • Hypotension (release of nitric oxide)
  • Capillary permeability
  • Flushing
  • Prostacyclin release
  • Tachycardia
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12
Q

What is the most accurate description of an antihistamine?

A

Inverse Agonist
They don’t prevent the release of histamine but responses

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13
Q

H1 receptors can be found in what areas?

A

Vestibular system
Airway smooth muscle
Cardiac endothelial cells

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14
Q

How do H1 receptor antagonists affect the following:
* Vestibular system
* Airway smooth muscle
* Cardiac endothelial cells

A

Reduce motion sickness
Prevent smooth muscle contraction
Provide cardiac stability (indicated in anaphylaxis)

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15
Q

What side effect is the biggest concern with 1st generation H1 receptor antagonists?

A

Drowsiness (sedation)
Take a 2nd generation to avoid this

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16
Q

Besides drowsiness, what other SE’s are seen with H1 receptor antagonists?

A

Blurred vision
Urinary retention
Dry mouth

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17
Q

Typically, what 1st generation H1 receptor antagonists do we use?

A

Diphenhydramine (Benadryl)
Promethazine (Phenergan)

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18
Q

Typically, what 2nd generation H1 receptor antagonists do we use?

A

Cetirizine (Zyrtec)
Loratidine (Claritin)

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19
Q

Diphenhydramine is typically used for what?

A

Antipruritic:
* Pre-treatment for procedure-related allergies
* Anaphylaxis

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20
Q

Diphenhydramine may inhibit the afferent arc of the _ _ _.

A

Oculo-emetic reflex
*Prevents emesis even if you “mash on the eye”; important for ocular surgeries *

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21
Q

Diphenhydramine can stimulate ventilation by augmenting the relationship of ___ and __ drive.

A

Hypoxic, Hypercarbic

Only if given as a solo administration

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22
Q

What is the typical IV dose of Benadryl?

What is the half-time of Benadryl?

A

25-50mg IV
(Can give 12.5 mg in geriatric cases)

7-12 hours

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23
Q

Which H1 receptor antagonist is a great anti-emetic and is used as a rescue and reduces peripheral pain levels (anti-inflammatory effects).

A

Promethazine (Phenergan)

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24
Q

What are the black box warnings for Phenergan?

A

Respiratory arrest in children under 2
IV infiltration, can cause tissue necrosis

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25
Q

What is the dose for Phenergan IV?
How long until time of onset?

A

12.5-25 mg
5 minutes

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26
Q

What is the elimination half-time for promethazine?

A

9-16 hrs

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27
Q

H2 receptor antagonists are most commonly used for what condition?

A

Duodenal ulcer disease / GERD

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28
Q

How do H2 receptor antagonists work?

A

Decrease hypersecretion of gastric fluid (H+) from gastric parietal cells and decrease cAMP, which will decrease gastric volume and increase pH.

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29
Q

What is the biggest concern of H2 receptor antagonist use?

A

Increase in serum creatinine by 15% d/t competition for tubular secretion

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30
Q

What are the side effects of H2 receptor antagonists?

A

Diarrhea
HA
Skeletal muscle pain
Weakened gastric mucosa d/t bacteria

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31
Q

Overgrowth of __ __ can increase pulmonary infections d/t weakened gastric mucosa from prolonged administration of H2 antagonist.

A

Candida Albicans

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32
Q

Which H2 receptor antagonists do we typically use?

A

Cimetidine (Tagamet)
Rantidine (Zantac)
Famotidine (Pepcid)

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33
Q

How is Cimetidine metabolized?

A

In the liver, by CYP450
Cleared in the urine

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34
Q

Cimetidine strongly inhibits CYP450, which can affect the metabolism of which drugs?

A
  • Warfarin
  • Phenytoin
  • Lidocaine
  • Tricyclics
  • Propranolol (Inderal)
  • Nifedipine
  • MEperidine
  • Diazepam
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35
Q

What are the adverse effects of Cimetidine?

A
  • Bradycardia
  • Hypotension (rapid infusion)
  • Increased plasma Prolactin (gynecomastia)
  • Impotence (Inhibits dihydrotestosterone binding to androgen receptors)
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36
Q

What is the dose of cimetidine?

What about renal dosing?

A

150-300mg IV

75-150mg IV
1/2 the dose

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37
Q

How is Ranitidine metabolized?

A

In the liver, CYP450
Cleared in the urine

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38
Q

Does Zantac cause inhibition of CYP450?

A

No

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39
Q

What is the dose of Ranitidine?

What about renal dosing?

A

50 mg diluted in 20 mL given over 2 minutes.

25 mg diluted in 20 mL given over 2 minutes.
1/2 the dose

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40
Q

If a patient is on Tagamet chronically, would you switch to Ranitidine for its lower cost?

A

No, if Tagamet is available, continue the patient on their medication

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41
Q

How is Famotidine metabolized?

A

In the liver, CYP450
Cleared in the urine

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42
Q

What interference is Famotidine involved with?

A

Interferes with phosphate absorption and can result in phosphatemia.

Bone fractures or hips hurting

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43
Q

What is the dosing for famotidine?

What about renal dosing?

A

20mg IV

10mg IV

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44
Q

What is the elimination half-time for Famotidine?

A

2.5-4 hrs
Most potent and longest of all H2 receptor antagonists

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45
Q

For long term management would Famotidine or Ranitidine be the appropriate choice?

A

Ranitidine (Zantac)

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46
Q

What group of drugs irreversibly bind to acid secretion pumps and inhibit the movement of protons (H+) across the gastric parietal cells?

A

Proton Pump Inhibitors

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47
Q

How many days does it take for the onset of PPIs?

A

3 to 5 days

48
Q

What are PPIs most effective against?

A

Controlling gastric acidity
Decreasing Volume

49
Q

PPIs are more effective than H2 receptors in what 4 areas?

A
  • Healing esophagitis
  • Healing ulcers
  • Relieving symptoms of GERD
  • Best treatment of Zollinger-Ellison Syndrome
50
Q

What are examples of PPI?

A

Omeprazole (Prilosec)
Pantoprazole (Protonix)
Lansoprazole (Prevacid)
Dexlansoprazole (Dexilent)

51
Q

What are better for short-term treatment of gastric issues? Long-term?

A

H2 and/or Dopamine blockers
PPIs

52
Q

What have PPIs been associated with?

A
  • Bone Fractures
  • SLE
  • Acute Intestinal Nephritis
  • C-diff
  • Vitamin B12
  • Magnesium Deficiency
53
Q

PPIs are known to inhibit what medications metabolism?

A

Warfarin

54
Q

PPIs block the enzyme that activate what medication?

A

Clopidogrel (Plavix)

55
Q

What is Omeprazole’s MOA?

A

Inhibits pumps present in parietal cells
66% maximum inhibition

56
Q

How is Omeprazole metabolized?

A

CYP metabolism

57
Q

What is the dosing of omeprazole?

If given PO, how long before surgery?

A

40mg in 100 mL NS given over 30 minutes

PO, at least 3 hours prior to surgery

58
Q

What are the side effects of omeprazole?

A
  • HA (crosses BBB)
  • Agitation (crosses BBB)
  • Confusion (crosses BBB)
  • Abdominal Pain
  • N/V
  • Flatulence
  • SB bacterial overgrowth
59
Q

What is the dose of Protonix?

How long before surgery can you give Protonix?

A

40mg in 100 mL given over 2-15 minutes

1 hour before to decrease gastric volume and increase pH (works as fast as ranitidine)

60
Q

How is Protonix metabolized?

A

CYP metabolism

61
Q

Pantoprazole has a greater bioavailability and elimination half-life compared to _

A

Omeprazole (Prilosec)

62
Q

PPIs are the treatment of choice for what conditions?

A

GERD
Gastroduodenal Ulcers
Acute upper GI Hemorrhage (Post-EGD treatment)

63
Q

What is given to treat NSAID ulceration?

A

Omeprazole

64
Q

What will protect the acidity of aspiration pneumonitis and be the most cost-effective for intermittent symptoms?

A

H2 antagonist

65
Q

What is a particulate antacid?

A

Aluminum or Magnesium based. Aspiration equals acid aspiration.

66
Q

What are the two particulate antacids?

A

Maalox
Mylanta

67
Q

What is a non-particulate antacid?

A

Sodium, Carbonate, Citrate, or Bicarb base.
Neutralize Acid.

68
Q

What is the one non-particulate antacid?

A

Sodium Citrate (Bicitra)

69
Q

What are long-term effects of all antacids?

A

If pH is too high, acid breakdown of food will be inhibited and acid rebound can occur.

70
Q

What are the long-term effects of magnesium-based antacids?

A

Osmotic diarrhea, neurological/neuromuscular impairment

71
Q

What are the long-term effects of calcium-based antacids?

A

Hypercalcemia, Kidney stones

72
Q

What are the long-term effects of sodium-based antacids?

A

Hypertension

73
Q

How does sodium citrate (Bicitra) neutralizes acid?

A

The Bicitra and acid are combined to make salt, CO2, and water, resulting in neutralization.

74
Q

Sodium citrate increases __________.

A

Intra-gastric volume

75
Q

Does sodium citrate protect against aspiration pneumonia?

A

No

76
Q

What is the dose of sodium citrate?

When does it lose its effectiveness?

A

15-30 mL

After 30-60 minutes

77
Q

Pregnancies are considered full stomach after _________ weeks.

A

12 weeks

78
Q

What types of drugs are known for stimulating gastric motility (prokinetic)?

A

Dopamine blockers

79
Q

How do dopamine blockers work?

A

Lower Esophageal Sphincter tone.
Stimulate Peristalsis.
Relax Pylorus and Duodeum

80
Q

Who is contraindicated by dopamine blockers?

A

Individuals who are dopamine depleted (Parkinson’s).

81
Q

What are the side effects of dopamine blockers?

A
  • Extrapyramidal reactions (easily crosses BBB)
  • Orthostatic Hypotension
  • Can affect the chemoreceptor trigger zone (antiemetic effect).
  • No change in gastric pH
82
Q

What are examples of dopamine blockers?

A

Metoclopramide (Reglan)
Domperidone - not available in the US
Droperidol (Inapsine)

83
Q

What is the FDA-cleared drug for diabetic gastroparesis?

A

Metoclopramide (Reglan)

84
Q

What are the side effects of Reglan?

A
  • Abdominal cramps from the rapid infusion
  • Muscle Spasm
  • Hypotension
  • Sedation
  • Increase Prolactin Release
  • Neuroleptic malignant syndrome
  • Decrease plasma cholinesterase levels

slow metabolism of succinylcholine, mivacurium, and ester local anesthetics.

85
Q

What is the dose of Reglan?

When do give before induction?

A

10-20 mg IV given over 3 to 5 minutes

15 to 30 minutes before induction

86
Q

Unlike Reglan, _____________ does not cross the BBB and has no anticholinergic activity.

It also increases __________ secretion by the pituitary to a greater degree.

This is not FDA-approved due to _________ and __________ but is available outside the country.

A

Domperidone

Prolactin

Dysrhythmias and Sudden Death

87
Q

What drug was initially developed for schizophrenia and psychosis?

Like Reglan, this drug can cause __________and __________ as adverse side effects.

A

Droperidol (Inapsine)

Extrapyramidal syndrome and Neuroleptic Malignant Syndrome

88
Q

What CNS depressants do you want to avoid with droperidol?

A

Barbituates
Opioids
General Anesthesia (lol)

89
Q

Droperidol is more effective than ___ for N/V.

Droperidol is equally effective to ____ mg of ____ for N/V.

A

Reglan

4 mg of Zofran

90
Q

What is the black box warning for Droperidol?

A

Prolonged QT intervals
Torsades with higher doses
Serious Drug Interactions: Amio, Diuretics, Beta Blockers, CCB, Steroids

91
Q

What is the dose for droperidol?

A

0.625 to 1.25mg IV

92
Q

____________ is released from the chromaffin cells of the small intestine and stimulates _______________ through 5HT3 receptors that cause __________.

A

Serotonin
Vagal Afferents
Vomiting

93
Q

Serotonin 5HT3 receptors are ubiquitous they are in the kidneys, lungs, colon, liver, and stomach. There is a large concentration of 5HT3 receptors in the ________ and __________.

A

Brain and GI Tract

94
Q

What group of drug that was originally used in chemo and radiation therapy related to N/V is now used for PONV? It is a competitive antagonist with almost no side effects.

A

5HT3 antagonist

95
Q

What are 5HT3 antagonists not effective against?

A

Motion sickness
Vestibular stimulation

96
Q

What are examples of 5HT3 antagonists?

A

Ondansetron (Zofran)
Granisetron (Kytril)
Dolasetron (Anzemet)

97
Q

Which drug is the first 5HT3 antagonist and does not cross the BBB.

A

Ondansetron (Zofran)

98
Q

What are the side effects of Zofran?

A

HA
Diarrhea
Slight QT prolongation

99
Q

What is the dose of Zofran for adults?

What is the plasma half-life?

A

4 or 8mg IV

4 hours (Give Zofran at the end of the case)

100
Q

What is the dosage of Zofran for children?

A

0.05-0.15 mg/kg IV
0.15 mg/kg oral

101
Q

The exact mechanism of this group of drug is unknown for N/V, but it centrally inhibits prostaglandin synthesis and control endorphin release.

There is also increased effectiveness for 5HT3 antagonist and droperidol.

This group of drugs also has an anti-inflammatory effect resulting in less post-op pain, and less opioid use.

A

Corticosteroids

102
Q

What is the diabetic risk of Decadron?

What is another side effect of Decadron?

A

Perioperative Hyperglycemia (minimal side effect with one dose)

Perineal Burning/Itching (rapid IV push)

103
Q

What is the dose of Decadron?

What is the delay in onset?

How long does the efficacy of decadron persist?

A

4mg or 8mg

2 hours (Give Decadron at the beginning of the case)

24 hours

104
Q

When will you consider giving an increased dose of decadron?

A

Airway trauma d/t multiple intubation attempts (12, 16, 20 mg)

105
Q

What are Scopolamine patches used for?

A

They are muscarinic antagonists (anticholinergic) for nausea and vomiting.

They have both central and peripheral effects (crosses the BBB, sedation)

106
Q

What are the side effects of Scopolamine patches?

A

Dilated pupils
Sedation

107
Q

Peak concentration hours for Scopolamine patches are between _________ and __________ hours.

How long does it take the patch to work?

A

8 to 24 hours

4 hours for onset of action.

108
Q

What is the priming dose of Scopolamine?

How much scopolamine will be given over the next 72 hours?

Where will the patch be placed?

A

140 mcg

1.5mg

Post-auricular

109
Q

What group of drugs is similar to epinephrine that stimulates the G-proteins, activates cAMP which will decrease Ca2+ entry, and relax smooth muscles in the airway?

A

Beta-receptor agonists (Bronchodilators)

110
Q

Bronchodilators can reduce inflammatory cell activation, directly relax smooth muscles, and increase FEV1 by _________% within ______ minutes (2 puffs).

A

15% improvement in 6 minutes

111
Q

How do you deliver an inhaled SABA?

A

Discharge inhaler while taking a slow deep breath over 5-6 seconds.
Hold your breath at max inspiration for 5-6 seconds.

112
Q

What percentage of the inhaled SABA reaches the lungs?

What percentage of the inhaled SABA is delivered to the lungs through mechanical ventilation?

How often are inhaled SABAs given?

A

12%

50-70%

Every 4 hours

113
Q

What are the side effects of beta agonists?

A
  • Tremor
  • Tachycardia
  • Transient decrease in arterial oxygenation
  • Hyperglycemia
114
Q

What are examples of bronchodilators?

A

Albuterol (Proventil)
Levo-albuterol (Xopenex)

115
Q

What are ways to deliver SABA?

A

Inhaler
Puff piece nebulizer
Syringe

Anesthesia Pharmacology Review (2 decks)

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