Prodigy- Opioid and Non-opioid analgesics Flashcards by Ashley Frugoli

What is responsible for the initial rapid drop in plasma concentration after an IV bolus of Fentanyl?

What about the second, slower decrease in plasma concentration?

the rapid distribution into the highly perfused organs (VRG)

The second, slower decrease in plasma concentration occurs as the drug distributes into the less well-perfused tissues such as muscles and apidose tissue

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What is the termination of analgeisa due to in opioids with a high Vd vs low Vd

high vd is due to redistribution of the drug away from its site of action

low vd drugs termination is due to clearance of the drug

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T/F: all 3 opioid receptor types can produce both supraspinal and spinal analgesia

True

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What is the mechanism by which the kappa receptor produces diuresis?

From Vasopressin inhibition

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Opioids produce an excitatory effect on what that results in miosis?

excitatory effect on the Edinger-Westphal nucleus of the oculomotor nerve produces miosis

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Even when the PaCO2 is controlled, ________ & __________ (2 drugs) are both associated with mild increases in the ICP of ____ - ____ mmHg

Fentanyl & Sufentanil

6-9mmHg

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Mechanism by which Morphine can cause bradycardia?

due to increased vagal activity

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What does it mean when the CO2 response curve shifts to the right?

It means a higher level of CO2 than normal is required to stimulate ventilation

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Morphine has been shown to (increase/decrease) the tone of the detrusor muslce of the bladder and (increase/decrease) the urinary sphincter muscle

Increase both

-increased sense of urgency and inability to urinate

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What is the only opioid that is entirely unaffected by hepatic disease?

Remi

(metabolized by plasma esterases)

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Where is the sphincter of Oddi located?

Where the CBD and pancreatic duct meet to empty into the duodenum.

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Which opioid is less likely to cause spasm of the sphincter of Oddi compared to the others?

Meperidine

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What is the most common side effect of neuraxial opioids?

which population is affected the most?

Pruritus (itching)

-Obstetric patients prob from the combined pruritic effect of estrogen

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What drug has been shown to be more effective than Benadryl, propofol, and naloxone in treating pruritus from neuraxial opioids and does not reverse analgesia?

Nalbuphine

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Hyperventilation and alkalosis will (increase/decrease) the non-ionized fraction of morphine

increase (will enhance the activity of morphine)

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T/F- patients taking MAOIs may exhibit an exaggerated response to morphine

True

-MAOIs can impair the conjugation of drugs with glucuronide.

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What populations exhibit prolonged clearance times with morphine? (2)

Elderly and neonates (within first 4 days of life)

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Is the potency of morphine noted to be greater in men or women?

Women

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T/F codeine is a derivative of morphine

True

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What’s the significant advantage of alfent over fent and sufent?

Rapid onset due to it’s low PKA resulting in 90% of the drug existing in the non-ionized form at physiologic pH

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For alfentanil, what is the time to equilibrate at the site of action?

1.4 minutes

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Which opioid should be used in caution with parkinsons patients and why?

Alfentanil bc it can result in acute dystonic reactions from disruption of central dopaminergic transmission by alfentanil.

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Major metabolite of fentanyl

Norfentanyl (inactive)

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What characteristic of Sufentanil accounts for the increase in Vd and elimination half time in obese patients?

High lipid solubility

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What does sufentanil bind significantly to? What population would this affect?

Alpha-1-acid glycoprotein Neonates (have decreased levels of AAG and would require lower doses bc there will be increased free fraction of the drug)

Sufentanil has a (high/low) hepatic extraction rate. what's the significance?

High ER - metabolism is more sensitive to changes in hepatic blood flow than to changes in the enzymatic ability of the liver to metabolize it.

What opioid can't be given epidurally or intrathecally and why?

Remi - it's prepared with glycine which can cause neurotoxicity by means of skeletal muscle weakness

During hypothermic coronary artery bypass, the clearance of remifentanil (increases/decreases) by ____% and why

decreases 20% - reflects the hypothermic effects on the activity of esterases in the blood and tissues

How does tramadol work?

It's an opioid that acts centrally on mu, kappa, and delta receptors to produce analgesia. It also inhibits the reuptake of NE & serotonin.

Why isn't tramadol routinely used in the peri-op period?

High incidence of N/V

Who should tramadol be avoided in?

Pts with a hx of epilepsy - can increase the risk of seizures.

an IM dose of Buprenorphine has an onset of ____ and duration of _____

onset 30 minutes duration 8 hours

T/F- respiratory depression from buprenorphine can be difficult to reverse with naloxone

True

Which opioid agonist/antagonist is similar to pentazocine and can increase the release of catecholamines, resulting in increased HR/BP

Butorphanol

Pentazocine is an opioid agonist/antagonist that works primarily on which receptors

kappa and delta

T/F pentazocine does not cause miosis

True

What are the 3 common opioid antagonists?

Naloxone Naltrexone Nalmefene

T/F- naloxone crosses the placental barrier

True- can cause withdrawal symptoms in the neonate

A significant advantage of nalmefene over naloxone

Longer duration of action (half time 10.8hrs)

Pure Mu receptor antagonist

Naltrexone

T/F- naltrexone is also used in the treatment of etoh abuse

True

Should pt's stop naltrexone prior to surgery?

Yes- 72 hours for the regular formulation; 30 days if ER.

Facilities with policies detailing drug testing should also be in compliance with practices outlined by which guidelines?

SAMHSA -Substance Abuse Mental Health Services Administration

If you suspect a peer of diverting narcotics and don't know what to do, who should yo contact first?

AANA Peer Assistance helpline

What is the recommended minimum recovery period before a CRNA who has been treated for narcotic diversion and substance abuse should return to clinical anesthesia? A. 6 months B. 3 years C. 1 year D. 1 month

C. 1 year

Which opioid is most likely to cause histamine release? A. Fentanyl B. Alfentanil C. Morphine D. Meperidine

C. Morphine

Constipation due to opioid administration is due primarily to A. increased peristalsis B. relaxation of gastric smooth muscle C. increased gastric emptying D. increased water absorption in the intestines

D. increased water absorption in the intestines

The clearance of sufentanil is most sensitive to A. blood esterase activity B. hepatic blood flow C. hepatic enzyme activity D. renal blood flow

B. hepatic blood flow

A substance abuse issue occurs involving a colleague. No patient is currently at risk for harm. The facility does not yet have a substance abuse policy. What should you do first? A. Notify the state board of medicine B. Perform an intervention with the person C. Call 911 D. Call the AANA Peer Assistance Helpline

D. Call the AANA Peer Assistance Helpline

Hospitals and facilities that institute drug-testing for substance abuse should be in compliance with the practices outlined by the _______ to alleviate concerns of a career being damaged by a false positive result. A. Substance Abuse Mental Health Services Administration B. Americans with Disabilities Act C. Food and Drug Administration D. Department of Medical Laboratories

A. Substance Abuse Mental Health Services Administration

Which piperidine opioid contains a methyl ester side chain

Remi -this shit allows it to be metabolized by plasma esterases

A patient is experiencing pruritus from the administration of an opioid for surgical pain. What is the most appropriate treatment for the itching? A. diphenhydramine B. naltrexone C. nalbuphine D. naloxone

C. nalbuphine

You are preparing to perform a general anesthetic on a patient taking methadone as part of his treatment for substance abuse disorder. Which opioid would be most appropriate for pain control during the case? A. Remifentanil B. Morphine C. Sufentanil D. Fentanyl

A. Remifentanil

Which of the following statements concerning the metabolites of morphine is correct? A. Morphine-6 glucuronide is a more powerful CNS depressant than morphine B. The metabolites of morphine are inert C. Morphine-6 glucuronide is highly lipid-soluble D. Morphine-3 glucuronide is a more powerful CNS depressant than morphine

A. Morphine-6 glucuronide is a more powerful CNS depressant than morphine

*All endogenous opioids are derived from three prohormones. Name them. (3)

Proenkephalin, prodynorphin, and pro-opiomelanocortin. *Nagelhout

*What are the two major methods by which opioids produce analgesia?

1) the direct blockade of ascending nociceptive signals from the dorsal horn of the spinal cord and 2) stimulate pain modulation pathways that descend from the midbrain to the dorsal horn of the spinal cord via the ventromedial medulla. *Nagelhout

*Is the analgesic effect of Mu receptors produced supraspinally, spinally, or peripherally?

Supraspinal *Nagelhout

*Is the analgesic effect of Kappa receptors produced supraspinally, spinally, or peripherally? What about Delta?

Both Supraspinal and spinal *Nagelhout

*What opioid receptor(s) are responsible for producing respiratory depression?

Mu, delta, kappa

*What opioid receptor(s) are responsible for producing nausea and vomiting?

What opioid receptor(s) are responsible for producing pruritus?

Mu and Delta (you go to the MD if your itchy)

*How do opioids depress the cough reflex?

They exert a direct effect on the medullary cough center.

*How do nitrous oxide, naloxone, and GABA receptor agonists influence the muscle rigidity seen with the administration of high doses of opioids.

Nitrous oxide significantly increases the incidence and degree of muscle rigidity seen with high-dose opioid administration. Naloxone and GABA receptor agonists such as propofol, thiopental, and benzodiazepines inhibit this response.

You are inducing a patient for coronary artery bypass surgery and administer a large loading dose of fentanyl. The patient becomes difficult to mask ventilate and you suspect chest wall rigidity from the narcotic. What step should you take? A. be patient as the effect is transient B. administer succinylcholine C. administer nitroglycerin intravenously D. administer glucagon immediately

B. administer succinylcholine

Which opioid can produce acute dystonic reactions in patients with untreated Parkinson's disease? A. alfentanil B. morphine C. fentanyl D. sufentanil

A. alfentanil

A patient undergoing general anesthesia takes buprenorphine for the treatment of substance abuse disorder. You would most expect that the response to A. inhaled anesthetics would be decreased B. systemic local anesthetics would be decreased C. opioids would be decreased D. neostigmine would be decreased

C. opioids would be decreased (not what I experienced)

During the preoperative evaluation, a patient states he is taking the short-acting form of naltrexone for the treatment of substance abuse disorder. You know that this agent should be discontinued at least _____ days before opioid administration. A. 3-7 B. 30 C. 10-14 D. 1-2

A. 3-7 days

Which opioid has the fastest onset? A. Sufentanil B. Morphine C. Fentanyl D. Alfentanil

D. Alfentanil

Compared to morphine, hydromorphone exhibits A. greater potency B. a slower onset C. a longer duration D. more euphoria

A. greater potency

Neonates may exhibit an increased free fraction of sufentanil primarily because they have A. decreased levels of alpha-1 acid glycoprotein B. decreased muscle mass C. decreased total body water D. increased albumin levels

A. decreased levels of alpha-1 acid glycoprotein

Sufentanil binds preferentially to the plasma protein A. alpha-1 acid glycoprotein B. hemoglobin C. myoglobin D. fibrinogen

A. alpha-1 acid glycoprotein

Which opioid will cause mydriasis? A. fentanyl B. meperidine C. morphine D. methadone

B. meperidine

Which of the following steps would be most appropriate for decreasing the severity of hypotension due to histamine release from morphine administration? A. Administer epinephrine 0.3 mg SQ B. Administer diphenhydramine 25 mg IV C. Place the patient in reverse Trendelenburg position D. Ensure adequate hydration

D. Ensure adequate hydration

Which of the following agents is classified as a piperidine? A. Remifentanil B. Meperidine C. Morphine D. Dilaudid

A. Remifentanil

Which of the following statements concerning the metabolites of morphine is correct? A. Morphine-3 glucuronide is a more powerful CNS depressant than morphine B. Morphine-6 glucuronide is a more powerful CNS depressant than morphine C. Morphine-6 glucuronide is highly lipid-soluble D. The metabolites of morphine are inert

B. Morphine-6 glucuronide is a more powerful CNS depressant than morphine

Which opioid is less likely to produce spasm of the sphincter of Oddi? A. fentanyl B. morphine C. glucagon D. meperidine

D. meperidine

The volume of distribution of sufentanil is _____ in obese patients because it has a _____ lipid solubility. A. increased, high B. decreased, low C. decreased, high D. increased, low

A. increased, high

The highest rehabilitation success rate for substance abuse occurs with a minimum of ___ inpatient treatment days and at least ___ treatment days total. A. 7 and 30 B. 14 and 28 C. 28 and 90 D. 90 and 365

C. 28 and 90

Which opioid receptor(s) is responsible for producing miosis?*

Mu and Kappa

What is the suggested dose of naloxone for ventilatory depression.

1-4 mcg/kg.

Upon what receptors does nalbuphine exert its action?*

antagonize mu receptor activity and agonize kappa

The advantage of nalbuphine over naloxone

patients experience much less reversal of analgesia.

What is the difference between naltrexone and naloxone?*

Naltrexone is a long-acting oral opioid antagonist used in the treatment of alcoholism and opioid dependence. Naloxone is administered intravenously.

How does butorphanol differ from nalbuphine?

Butorphanol is similar to nalbuphine in that it is a kappa receptor agonist and a weak mu receptor antagonist, but it has greater analgesic qualities than nalbuphine and produces more sedation when used clinically.