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Anesthesia Pharm > Psychiatric Drug > Flashcards

Psychiatric Drug Flashcards

1
Q

How long before the antidepressants take effect?

A

Clinical Onset often takes up to 2 weeks

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2
Q

What are the types of antidepressants

A
  1. Tricyclic Antidepressants (TCA)
  2. Selective Serotonin ReUptake Inhibitors (SSRI)
  3. Atypical Agents
  4. Monoamine Oxidase Inhibitors
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3
Q

MOA of TCA

whats the common uses

samples of TCA

A

Mechanism of action

  • Inhibit synaptic reuptake of norepinephrine and serotonin
  • Variable antagonist activity at histamine, anti-muscarinic acetylcholine, α1 adrenergic, NMDA, μ1-opioid receptors, sodium channel blockade

Common medications

  • Amitriptyline
  • imipramine
  • desipramine
  • doxepin
  • nortriptyline

Common uses

  • Depression, chronic pain (neuropathic and fibromyalgia), some forms of acute pain
  • Use decreasing due to side effects
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4
Q

What are the common side effects of TCA

A
  • Postural Hypotension
  • Urinary retention
  • blurred vision
  • dried mouth
  • Hypotension - common
  • QTC prolongation
  • DELIRIUM - CHOLINERGIC DEFICIENCY
  • SEROTONIN SYNDROME
  • NARROW THERAPEUTIC INDEX
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5
Q

drug class that has a narrow therapeutic index

what are the changes that you can see?

A

TCA

Narrow therapeutic index

  • Can cause EKG changes particularly with overdose; non-symptomatic EKG changes will subside with time
  • Flattening/inversion of T waves, widening of QRS complex, prolongation of QT interval, bundle branch block, premature ventricular contractions, conduction abnormities, ventricular arrhythmias

​​Reduction of seizure threshold (dose-dependent) – Caution use with tramadol or meperidine

Serotonin syndrome

  • Avoid use with MAO-I – inhibit breakdown of neurotransmitters (i.e., dopamine, serotonin, norepinephrine)
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6
Q

What effect will chronic TCA use have with pressors

A
  • Decreased response to sympathomimetics with chronic (>6 weeks) TCA use [MORE DRUG TO GET APPROPRIATE RESPONSE]
    • Adrenergic receptors are sensitized, downregulation of β receptors or catecholamine stores depleted
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7
Q

What effect will acute TCA use have with pressors

A

Sympathomimetic agents

  • Exaggerated response of sympathomimetics with new TCA starts – Increased amount of catecholamines present to stimulate post-synaptic receptors due to norepinephrine reuptake blockade
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8
Q

What effect will TCA use have with the induction of anesthesia

A
  • Possible increased incidence of cardiac dysrhythmias (mostly with halothane)
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9
Q

you have a patient on TCA. which drug for N/V when given may cause excessive sedation?

A

Anticholinergic agents (i.e., diphenhydramine,

scopolamine)

  • Additive side effects with anticholinergic drugs –> increased risk for excess sedation, postoperative delirium, confusion
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10
Q

Why would there be an augmented analgesic and ventilatory effects of opioids when used with TCA?

A

Because TCA has CYP450 inhibition

–> may increase opioids and sedatives in the system

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11
Q

SSRI MOA

A

Mechanism of action

– Major mechanism: inhibits the reuptake of serotonin

– Minor mechanisms:

  • Inhibits norepinephrine reuptake
  • Inhibits dopamine uptake
  • Histamine, musarinic receptor antagonist
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12
Q

SSRI that has an active metabolite

A

Fluoxetine

* maybe given to a patient without parenteral access and liver dysfunction because of an active metabolite and long half-life (1-4 days)

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13
Q

Your patient on Fluvoxamine has been NPO for 45 hours (2ish days). what can you expect?

A

You may see withdrawal symptoms

* Fluvoxamine has the shortest half-life among SSRIs (15 h)

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14
Q

SSRI common SE

A

*Should not have much SEDATION

QTC prolongation

*lesser effects when it comes to sedation as compared to TCA

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15
Q

SSRI: FLUOXETINE

ADVERSE SE

A
  • BRADYCARDIA
  • SYNCOPAL OCCASIONAL OCCURENCE IN ELDERLY PATIENTS
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16
Q

What can you expect in an SSRI withdrawal?

when do you see it?

A
  • Dizziness,GI complaints,flu-like symptoms,anxiety, insomnia, paresthesias, myalgia, visual disturbances
  • Requires atleast ~1month therapy to be at risk
  • More severe with shorter acting agents paroxetine,Fluvoxamine)
  • Seen within 1-7days after discontinuation
  • Taper before discontinuation
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17
Q

Serotonin Syndrome

A

– Avoid use with MAO-I or have an adequate washout

– Cautious use with drugs with MAO-I properties(i.e, opioids, linezolid, methylene blue)

– Have adequate washout of the drug from the system if possible

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18
Q

MIRTAZAPINE

POTENT ANTAGONIST OF

A
  • Potent antagonist of 5-HT2 and 5-HT3 serotonin receptors and H1 histamine receptors
  • Moderate peripheral α1 adrenergic and muscarinic antagonist
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19
Q

NE:SE reuptake inhibitors

SE

A

decrease seizure threshold

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20
Q

TRIAZOLOPYRADINES

sample agents

used for insomnia

where is it metabolized?

SE?

A

Agents

  • trazodone
  • nefazodone

Mechanism of action

  • Serotoninreuptakeinhibition
  • α1 antagonist, histamine antagonist

Hepatic metabolism through CYP450

  • +activemetabolites
  • Inhibits CYP450

Common adverse effects

  • Qtc Prolongation
  • Sedation
21
Q

Anesthesia considerations in patients receiving SSRI

SIGNS OF Serotonin Syndrome

when does it occur?

what is the tx

what is the ideal washout period before starting MAOI inhibitor?

A

Signs of serotonin syndrome (occurs within 24h)

  • Hyperthermia[fever!!], confusion, agitation, autonomic hyperactivity, myoclonus, hyperreflexia, diaphoresis, tremor, diarrhea, neuromuscular abnormalities, ocular clonus
  • Treatment: stop offending agent + begin supportive care + serotonin antagonists
  • Serotonin antagonists: cyproheptadine –

Prevention

• Ideal washout period before starting MAOI inhibitor is 14 days

22
Q

If your patient got codeine, what can happen to it when given with SSRI?

A

SSRI can inhibit the metabolism of Codeine to morphine

  • may get inadequate analgesia
23
Q

DRUGS THAT INCREASE THE RISK OF SEROTONIN SYNDROME WHEN GIVEN WITH SSRI

A
  • Antiemetic (metoclopramide, ondansetron)
  • Fentanyl
  • Linezolid
  • Meperidine
  • Methadone
  • Tramadol
  • Valproic acid
24
Q
A
25
Q

SE OF BUPROPRION

A

SEIZURE RISK

26
Q

MAOI SE

A

SEDATION

THE FACT THAT THERE ARE DRUG INTERACTION!

27
Q

How long is the duration of MAOI inhibition?

A

10 - 14 days

28
Q

MAO- I

  • what does it do to tyramine
A
29
Q

How will MAOIs affect vasopressor effects?

A

May increase risk of vasopressor effect and hypertensive crisis

  • Inhibits systemic clearance of catecholamines via inhibition of MAO- dependent degradation
    • May need to use 1/3 of the normal dose of vasoactive medication
30
Q

What drugs should you absolutely AVOID with MAOI?

burn this in your brain

A

MEPERIDINE AND TRAMADOL

31
Q

LITHIUM

MOA

What is the goal?

A

Goal cerum concentrration

(maintenance)

0.6 - 1 meq/L

32
Q

LITHIUM

CHRONIC SIDE EFFECTS

A

CHRONIC SIDE EFFECT

  • Nephrogenic diabetes insipidus
  • Polyuria/ polydipsia
  • Hypothyroidism
  • Myxedema coma
33
Q

LITHIUM

ACUTE OVERDOSE

A
  • Nausea, vomiting, diarrhea
  • Confusion
  • Tremor
  • Myoclonus
  • Seizures
  • Coma
  • T-wave inversion Ventricular arrhythmias
34
Q

Conditions that are contraindicated with Lithium

may increase lithium toxicity

A

Renal Insufficiency - highly renally cleared

Hyponatremia

90% of Li+ is reabsorbed in proximal convoluted tubule and competes with Na+ reabsorption

35
Q

DRUG INTERACTIONS pertinent to anesthesiology

A

mostly risk for AKI

so be careful with diuretics

36
Q

What did Mona say about Typical Antipsychotics?

A

that they are not much used anymore– probably just Haldol

only because it’s very convenient

its IV and can also be given IM

37
Q

what do Antipsychotics block?

MOA?

A

everything.

Mechanism of action

  • Blocks histamine, α1 , cholinergic, dopamine, serotonin receptors to varying degrees
  • Typical antipsychotics
    • High D2 antagonism and low 5-HT2A antagonism
  • Atypical antipsychotics
    • Moderate to high D2 antagonism and high 5-HT2A antagonism
38
Q

How ARE Antipsychotics

Metabolized?

A

LIVER JUST LIKE EVERYTHING ELSE

extensive CYP

hALF LIFE 18-40 HOURS

39
Q

Antipsychotic side effects

what do you worry about?

WHAT ARE THE TREATMENTS?

TD

DY

AKA

PARK

A

movement type of disorders

Tardive dyskinesia occurs in up to 20% of patients taking antipsychotics for >1 year

  • No treatment (anticholinergics worsen symptoms)

Dystonia occurs in ~2% of patients within first 72 hours

  • TREATMENT:*** Response quickly to ***IV diphenhydramine 25-50 mg, Benztropine 2 mg, dose reduction/drug avoidance

Antipsychotics: Extrapyramidal side effects

Akathisia

  • Treatment: propranolol 20-120mg/day(generallyfirstline), benzodiazepines, anticholinergic (benztropine), amantadine or clonidine

Parkinsonism

  • Treatment : dose reduction/drug avoidance and anticholinergic (benztropine)
40
Q

TREATMENT FOR TARDIVE dyskinesia

A

No treatment (anticholinergics worsen symptoms)

41
Q

TREATMENT FOR DYSTONIA

A

Dystonia occurs in ~2% of patients within first 72 hours

TREATMENT: Response quickly to IV diphenhydramine 25-50 mg, Benztropine 2 mg, dose reduction/drug avoidance

42
Q

TREATMENT FOR AKATHISIA

A

Akathisia

Treatment: propranolol 20-120mg/day (generally first line), benzodiazepines, anticholinergic (benztropine), amantadine or clonidine

43
Q

TREATMENT FOR PARKINSONISM

A

Parkinsonism

Treatment : dose reduction/drug avoidance and anticholinergic (benztropine)

44
Q

a rare but fatal condition resulting from abrupt dopamine blockade

A

NEUROLEPTIC MALIGNANT SYNDROME

May occur even after discontinuation of antipsychotics especially if long acting depot agents are used

  • high fever and profound muscle contraction
  • rigidity

rhabdo

45
Q

SEVERE NEUROLEPTIC MALIGNANT SYNDROME CAN BE TREATED WITH?

A

DANTROLENE IV

*pt might be unable to take PO medications

46
Q

DRUGS THAT WILL INCREASE THE RISK fOR MALIGNANT HYPERTHERMIA

A
  • Malignant hyperthermia associated with anesthesia and with central anticholinergic syndrome may mimic neuroleptic malignant syndrome
  • Additive effect with sedating medications
  • QTc prolongation (common drugs used perioperatively)
47
Q

Where are benzos metabolized?

If you have a pt that was on benzos before their liver resection, what should you consider before restarting the medication?

A

LIVER

* THINK BEfore you start the same dose that they are at home

* LIVER DYSFUNCTION –> RESP. DISTRESS, EXTRA SEDATION

48
Q

Anesthesiology considerations in patients receiving benzodiazepines

A
  • Additive effects with other sedating agents
  • Increase sensitivity in elderly patients
  • Careful with dosing in patients after hepatectomies or with new onset liver dysfunction
  • Delirium associated with benzodiazepines
  • Abrupt stopping of chronic therapy can precipitate withdrawal
  • May cause prolonged sedation
  • Perform careful medication reconciliation

Anesthesia Pharm (25 decks)

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