Questions - student, resp, and cv Flashcards
Ms. Maringo is a 45 year old female with a history of hypertension who came to OR for an elective aneurysm clipping. Sheweighs 100 kg. Her list of home medications includes lisinopril 10mg daily and a daily multivitamin. The surgeon has indicated that her systolic blood pressure parameters should be maintained between 90-110 during the case. She was put on an infusion of Nicardipine which was titrated to 15mg/hr without sufficient reduction in blood pressure. The SRNA started her on a sodium nitroprusside infusion knowing its onset is within seconds. She has been requiring higher doses of nipride to maintain the same blood pressure. She is currently tachycardic with an elevated mixed venous oxygen on 5mcg/kg/min of sodium nitroprusside. Her ABG is indicative of metabolic acidosis. Which of the following would be the best action by the SRNA? (SELECT 2)
A. Give 2 units of vasopressin
B. Stop the Infusion of Sodium nitroprusside and maintain BP with Esmolol
C. Administer 400 mg of methylene blue
D. Put the patient on 100% Fi02
B. Stop the Infusion of Sodium nitroprusside and maintain BP with Esmolol
D. Put the patient on 100% Fi02
Rationale: Sodium nitroprusside is known to cause Cyanide toxicity when dosage exceeds 500mcg/kg at infusion rates greater 2mcg/kg/min. “Clinically the development of metabolic acidosis, increased mixed venous oxygen content, tachycardia, and tachyphylaxis during sodium nitroprusside use are signs of cyanide toxicity” (Nagelhout, 2014 p.199). “Treatment of cyanide toxicity consists of discontinuing the sodium nitroprusside infusion, administering oxygen, and treating metabolic acidosis” (Nagelhout, 2014 p.199). Vasopressin is not required to treat cyanide toxicity. While methylene blue is used to treat cyanide toxicity 400 mg is not the right dose.
Mrs. Doubtfire, a 66 year old female, weighs 125kg and is now 72 hrs post CABGx 3. She is slowly being weaned off the epinephrine drip and is currently receiving an infusion rate of 0.08mcg kg/min. Her initial vitals and labs from 72 hrs ago read as follow : HR : 98, BP: 108/67, CO: 8L/min, SVR : 900 dynes/ sec/cm5 , Spo2 : 100% on 6L NC . Na+ : 139 K: 4.5 Blood Glucose : 118 on Chem 7. Urinary output average at around 1.5 ml/kg/hr. Which of these changes in value would reflect the pharmacodynamic effects of the continuous Epinephrine infusion :
A. Blood Glucose 68, frequent PVC , BP 120/110, 24hr UO: 886ml
B. Blood Glucose 168, multifocal PVCs, SVR 650 dynes/sec/cm5 , K+3.5, lactate 4mmol/L
C. Blood Glucose 168, multifocal PVCs , SVR 1800dynes/sec / cm5 , HR : 118
D. None of the changes are remotely related to the epinephrine drip .
Correct Answer: B
Rationale: In small doses epinephrine may well be useful as a sympathomimetic agent in patients on responsive to indirect actually acting agents and in those in whom simultaneous B1 (cardiac stimulation) and B2 receptor stimulation (vasodilation) may be helpful. Epinephrine B1 effect produces marked positive inotropic, chronotropic, and dromotropic effects . In addition, the corresponding increase automaticity of all foci , including ectopic Foci , May lead to arrhythmias. With low doses of epinephrine 10 µg per minute, the peripheral vascular promotes the redistribution of blood flow to skeletal muscle, thereby producing a decrease in systemic vascular resistance. B2 stimulation leads to activation of the renin-angiotensin system, and also to an increase in lipolysis, glycogenolysis, gluconeogenesis, ketone production , and lactate released by skeletal muscle. Insulin secretion is inhibited by an overriding B2 stimulation. Simulation also can cause transient hyperkalemia as potassium follows Glucose out of hepatic cells . This is followed by a longer hypokalemia as B2 stimulation then forces this extra potassium into Red Blood cells .
Nagelhout pages 555-556 (ebook)
During the preop evaluation of your 18-year-old patient scheduled for a tonsillectomy, he begins to complain of shortness of breath with an oxygen saturation of 88%. You check a pulse and detect a rate greater than 100 BPM. 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 medication would the astute SRNA know to administer to control the rate? A. Verapamil B. Carvedilol C. Diltiazem D. Nitroglycerin
Correct Answer: C. Diltiazem
Rationale: Diltiazem is one of the most common calcium channel blockers used for an antiarrhythmic. Verapamil is not indicated for the treatment of AF associated with WPW syndrome.
Nagelhout pg 178, second column, third paragraph
A 54 year old female undergoing a CEA develops severe hypertension upon induction. She is started on a vasodilator. She later presents with a heart rate of 115 and increased mixed venous oxygen content. Her ABG reveals metabolic acidosis and she requires increased dosages of the vasodilating agent of choice to achieve a therapeutic blood pressure. The astute SRNA would know that what drug would produce these symptoms?
A. Hydralazine 40 mg
B. 800 mcg of Sodium Nitroprusside at 1 mcg/kg/min C. Nitroglycerin 20 mcg/min
D. 550 mcg of Sodium Nitroprusside at 2.5 mcg/kg/min
Correct Answer: D. Sodium Nitroprusside 2.5 mcg/kg/min
Rationale: When more than 500 mcg/kg of sodium nitroprusside is administered faster than 2 mcg/kg/min, cyanide is generated faster than the patient can eliminate it. Clinically the development of metabolic acidosis, increased mixed venous oxygen content, tachycardia, and tachyphylaxis during sodium nitroprusside use are signs of cyanide toxicity.
Nagelhout pg. 177-178
A 65-year-old male comes into the hospital c/o sever chest pain. He has no significant medical history. Vitals are as follows: BP: 176/110, HR: 66, O2: 98% RA. An EKG is performed showing ST elevation in leads II, III, aVF. The astute SRNA knows not to give which medication?
A.Nitroglycerin
B. Metoprolol
C. Hydralazine
D. Labetalol
Correct Answer: A – Nitroglycerin
Rationale: Pt is having a R-ventricular MI. Nitrates should be avoided in patients with a blood pressure less than 90 mmHg, a heart rate less than 50 bpm or above 100 bpm, and in patients with right ventricular infarction.
Nagelhout 5thed., Chapter 13 – Pg. 199
During a laproscopicappendectomy, a 65 year old develops severe hypertension unresponsive to first line medications, the astute SRNA moves to a differentsymmpatholyticthat resolves the hypertension briefly. However, it is short-lived and 15 minutes later the pressure jumps to 190/115. The knowledgeable SRNAknows that this is due to howthe drug is metabolized by blood esterases, and initiates a drip instead. What drug is the SRNA initiating and at what starting dose? A. Fenoldopam: 0.1 mcg/kg B. Sodium Nitroprusside: 0.3mcg/kg/min C. Clevidipine: 1 mg/hr D. Labetalol: 2 mg/min
Correct Answer: C – Clevidipine: 1 mg/hr
Rationale: Clevidipine(Cleviprex) is a dihydropyridineL-type CCB indicated as an IV antihypertensive. It is highly selective for vascular muscle and does not affect myocardial contractilityor conduction. Its hypertensive effect is largely due to arterial vasodilation. Clevidipine is rapidly metabolized by nonspecific esterasesin the blood. the terminal half-life is approximately 15 minutes. The starting doeseis 1-2 mg/h, titrated up to 16 mg/h or less, according to patient response. (Nagelhout, pg 179).
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?
A) The patient must take HTN medication but does not remember because there is no reason for her BP to be 182/88.
B) The patient is having withdrawal symptoms from abrupt discontinuation from her Pindolol.
C) The patient is nervous about her surgery, as soon as she takes some Versed her HR and BP will go down.
D) The surgery should be cancelled, and the patient restarted on her Pindolol and come back tomorrow or her nephrectomy.
Correct Answer: B - the patient is having withdrawal symptoms from abrupt discontinuation from her Pindolol.
Rationale: Long term therapy with B- blockers leads to up regulation of B receptors or an increase in the absolute number and activity of receptors. This phenomenon is suspected to be the underlying cause of the withdrawal syndrome seen with abrupt discontinuation of B adrenergic antagonist use.A is not correct because there is no reason to think the patient is not a good historian, plus you have a list of her medications. C is not correct because there is no indication in the question that the patient is nervous. D is not correct because this is a solution to the question and not the most likely reason for the patient’s vital signs.
Nagelhout Nurse Anesthesia 6thedition electronic version page 573 last paragraph.
Ms. Mommy Tobe is complaining of feeling lightheaded and seeing stars after a recent epidural. She is 39 weeks and two days gestation with her first child. Labor is progressing steadily. Ms. Mommy Tobe is now nauseated and with emesis. What would be appropriate interventions at this time? SELECT ALL THAT APPLY:
A. Administer a rapid fluid bolus B. Assure the patient everything is “normal “and it will pass. C. Give 4 mg of Zofran D. Rapidly push Ephedrine IV E. Administer phenylephrine
Correct Answer: A & E
A. Administer a rapid fluid bolus
E. Administer phenylephrine
Rationale: The patient is hypotensive post regional anesthesia. The onset of her nausea and vomiting is likely related to her low blood pressure. A fluid bolus is an appropriate intervention after regional anesthesia to reduce the incidence of hypotension. Since the patient is symptomatic of low blood pressure, phenylephrine is the recommended treatment for maternal hypotension over ephedrine because “ephedrine produces increases in fetal metabolic rate leading to fetal acidosis due to beta stimulation and phenylephrine does not.
Source: Nagelhout, page 190 of the PDF edition
Mr. John Doe was admitted to the ICU for hypertensive crisis overnight. Vital signs on admission were as follows: BP 202/120, HR 63, SaO2 97 on 2L nasal canula, RR 18. He was started on nitroprusside 2mcg/kg/min but is now at 7mcg/kg/min 10 hours after. You notice his HR changed from 63 to 101 and acute mental status changes have also been noted. An ABG was drawn and shows: pH 7.22, HCO3 15, CO2 36. What pro-drug could be administered to help reverse this patient’s condition?
Methylene Blue Propranolol Codeine Sulfanegen Sodium Thiosulfate
Correct Answer: NO correct answer was given.
Rationale: Treatment of cyanide toxicity consists of discontinuing the sodium nitroprusside infusion, administering oxygen, and treating metabolic acidosis. Sodium nitrite 3%, 4 to 6 mg/kg, can be administered over 3 to 5 minutes to promote the production of methemoglobin so that excess cyanide ions can be bound. Sodium thiosulfate, 150 to 200 mg/kg over 15 minutes, can be administered every 2 hours as needed; vitamin B12 also can be administered. If available, hydroxycobalamin can be used. Methylene blue 1 to 2 mg/kg may also be useful. A new prodrug, sulfanegen sodium, is also being tested.
Nagelhout Pg 178 (Hardcopy
An SRNA arrives to a code situation in which the patient is found to be in a severe heart block that has shown to be unresponsive to atropine.The patient has a history of coronary artery disease and a three day history of fatigue and shortness of breath.The attending physician gives an order for Isoproterenolto be given for the refractory heart block. The SRNA immediately expects what if this medication is given?
A. the powerful inotropicand chronotropic effects of this medication will be effective in treating the patients heart block
B. decreased coronary perfusion accompanied by increased myocardial oxygen consumption that may be detrimental to this patient
C. the rhythm will convert to sinus tachycardia almost immediately
D. the increase in SVR will improve coronary perfusion and decrease myocardial ischemiarisk for the patient
Correct Answer: B
Rationale: Isoproterenolis a high risk medication in pts with history of CAD due to the excessive tachycardia, induction of myocardial ischemia, and arrhythmia production factors. Giving this medication to a patient with a compromised heart would put the patient at risk for MI worsening the situation.
Nagelhout 167
A 48-year-old male patient preparing to undergo an exploratory laparoscopy. He has a history of hypertension, GERD, Anxiety, OSA all of which are being treated with common medications and therapies. Surgical history includes an operation to have his gall bladder removed 3 months ago by the same surgeon. The patient weighs 100kg and is 72 inches tall. He is a ex smoker and has not had any problems with anesthesia in his previous procedures. He states that he has been NPO since midnight (16 hours). The patient is in a good mood and states that he doesn’t feel worried at all because he trusts the surgeon and the hospital staff. His vital signs are HR: 107 RR: 16 O2: 99% on room air BP: 225/110. T 99°F
With consideration to the patient’s vital signs, which of the following does the SRNA need to consider when moving forward with the pre-operative assessment?
A. The patient’s blood pressure and heart rate are of no significant concern at this time because the anesthetic technique will help minimize the complications.
B. It would be important to ask the patient if they take any antiplatelet medications regularly and whether or not they have taken them this morning.
C. The patient has a history of anxiety so administration of 2mg of versed IV will safely reduce the physiologic effects of his acute anxiety response.
D. The patient’s blood pressure is a major concern and continuation of antihypertensives such as Catapres should be done through the perioperative timeframe.
Correct Answer: D
Rationale: According to Nagelhout6thpg 169. under Clonidine: “rebound hypertension, seen after abrupt discontinuation of clonidine is a major concern. The resulting increase in catecholamine levels manifest as tachycardia and hypertension. Continuing medication throughout the perioperative period Is essential.”
A patient with Parkinson’s disease comes in for an elective surgery. The patient’s Parkinson’s therapy consists of tolcapone and levodopa. As the astute SRNA, what would you consider with dosing of epinephrine if it were required intraoperatively?
A. Reduce the initial dose as the effects may be enhanced
B. Increase the initial dose as the effects are reduced
C. The dose should not be altered
D. Epinephrine should be avoided
Correct Answer: NO correct answer was given.
A??
Rationale: Tolcapone is a Catechol-o-methyltransferase (COMT) inhibitor and is combined with Levodopa as an adjunct to Parkinson’s therapy.(COMT is an enzyme that is responsible for the breakdown of catecholamines). When used in combination, it decreases the metabolism of certain cardiac drugs including isoproterenol, dobutamine, dopamine, norepinephrine and epinephrine.Reduced doses should be started initially until the response can be assessed. (Nagelhout p. 202 – eBook).
John, a 42year 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 interventionand reason behind that choice?
A. Bolus a liter of NS then a liter of LR until increase in bp, - reason - always give fluid before giving pressors
B. Dopamine infusion for BP - reason(s) - will increase CO, help the kidneys, and is a first line of therapy for shock, will increase survival
C. Norepinephrine infusion for BP - reason - first line of therapy for shock - mainly alpha - does not depend as much on sensitivity of Beta receptors
D. Dopamine infusion for BP - reason - first line therapy of shock, less adverse effects than Levophed such as arrhythmias and increased mortality
E. epinephrine for bp- acts on all receptors, first line therapy for shock, can help in caseof an allergic reaction
F. Let the already performed interventions work, and wait patiently for the bp to riseas to not increase the workload and o2 demand on the heart
Correct Answer: C – Norepinephrine infusion for BP
Rationale:
Wrong - Answer A: The patient already receivedthe amount of fluid per protocol for sepsis at the institution and would only be increasing 3rd space edema by giving even more fluid at such a rapid rate.
Wrong answer - D: In Nagelhout pg 166,when comparing the first line therapy of norepinephrinevs dopamine for shock, “A 2016 meta-analysis suggest that they are equally effective, although dopamine produces more adverse events such as arrhythmias, and possibly increased mortality. “ Thus the patient is already having PVCsand PACs, we do not want increase chance of arrhythmias or increased mortality.
Correct - C: Under Dopamine on pg. 167 it states, “Norepinephrine is now considered first-line therapy for a patient in shock. Some clinicians have found dopamine to have a poor response in cases of gram-negative sepsis, because the sensivity of Beta-receptors is diminished due to a down-regulation.“
It states in the stem of the question that the patient is suspected of having gram-negative sepsis, thus dopamine would have a poor response and would be a poor choice for this patient.On pg. 165 under Norepinephrineit states, “Norepinephrine….has little beta-2 activity at low doses, and the end result is, for the most part, unopposed alpha stimulation”
Wrong B: It also states on pg 167, in regards to renal dose with dopamine, “The stimulation of dopamine receptors in the renal artery promotes an increase in renal blood flow and a resultant increase in glomerular filtration rate and urine output. However, the benefits of so-called “renal” dopamine are in doubt, and many clinicians have abandoned the practice. The urine output increases, but longterm morbidity and mortality do not improve”
According to the above statement, many people are abandoning the renal dose dopamine and even though it may increase urine output, does not improve morbidity and mortality.
Wrong - answer E: epinephrine is not usually used first, especially with the patients HR being 102, and epi has a stronger inhibition of insulin secretion compared to norepi, thus causing a need would be increased for another drip, such as insulin, if patient was started on an epinphrine drip.
pg. 167 “Norepinephrinedoes have some generalized metabolic effects, such as a decrease in insulin production, but these metabolic effects are present to a lesser degree than those seen with epinephrine.”
wrong - F: It should go without saying that a BP of 74/41 is not okay and perfusion to kidneys, brain and other vital organs may be compromised, so simply doing nothing is not okay.
Nagelhout, J. J., & Elisha, S. (2018). Autonomic and Cardiac Pharmacology. InNurse Anesthesia(Sixth ed., pp. 165-167). St. Louis, MO: Elsevier.
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 theMOSTappropriate treatment to help improve your patient hemodynamic profile?
A. Vasopressin 0.5 – 1-unit IV push followed by a vasopressin drip
B. Methylene blue 1-2 mg kg over 10 minutes
C. Albumin 25% 100 ml
D. Hydralazine 20 mg followed by a 100 ml fluid bolus
Correct Answer: A
Rationale: The ACE inhibitors may result in an increase in refractory hypotension during induction and maintenance of anesthesia. Vasoplegic syndrome is defined as an unexpected refractory hypotension under general anesthesia with a mean blood pressure of less than 50 mm Hg. A 0.5 to 1.0-unit bolus of vasopressin followed by an infusion dose of 0.03 units/min is the indicated treatment if the initial treatment is not effective.
Nagelhout chapter 13 page 180
You receive a patient from the ED who presented to the hospital with a chief complaint of “periodic chest painthat radiates across to his left arm, and occasionally up to the jaw.” You originally begin to think that the patient is presenting with classic signs of angina, but upon further assessment, the patient tells you that theepisodes of chest pain occur more frequently at rest, and you realize the patient has anormal EKG readinganddoes not have elevated cardiac enzymes. You also note that the patient waspositive for cocaine on his urine drug screenupon admission, and he verbalizes that his last use of cocaine was the night before, and also mentions that his episodic chest pain “began shortly after this.”
With your abundant knowledge, you begin to realize the most likely probability is that the patient is experiencing coronary artery vasospasms. You know that theBEST classification of cardiac drugs for this patient’s conditionare administered primarily due to their ability to:(CHOOSE 2):
A. Produce a direct effect on relaxation of arterial smooth muscle, therefore, leading to reduced afterload that will reduce the workload of the ventricles
B. Produce vasodilation, and therefore, increase coronary blood flow by reducing influx of calcium ions into vascular smooth muscle
C. Produce vasodilation through direct effect on Alpha-2 receptors, therefore, increasing coronary blood flow to the heart
D. Produce a negative inotropic effect on the heart, therefore decreasing myocardial workload and oxygen consumption
Correct Answers: B & D
Rationale: “CCBs also exert a negative inotropic effect on the heart, which can be beneficial in patients with angina…Cardiac contractility is dependent on the influx of calcium into cardiac cells, and this is slowed by calcium channel blockers”.
“Calcium channel antagonists produce relaxation of vascular smooth muscle, resulting in vasodilation. Systemic vasodilation of both arteries and veins results in decreased preload and afterload…Coronary arteries also are affected, with an increase in coronary blood flow. The CCBs are especially beneficial in the prevention of angina resulting from spasm of the coronary arteries, such as with Prinzmetal’s angina.”
Nagelhout, Ch. 13, p. 178
In regard to cyanide toxicity, the astute SRNA would correctly identify that the administration of sodium nitrite 3% will induce _________ which facilitates binding of excess cyanide ions.
A. Rhodanese-catalyzed conversion
B. Methemoglobinemia
C. Vasoplegic syndrome
D. Erythrocyte preservation
Correct Answer: B – Methemoglobinemia
Rationale: The chemical structure of sodium nitroprusside contains five cyanide ions, which are released upon metabolism by plasma hemoglobin. One cyanide ion binds methemoglobin to form cyanmethemoglobin, whereas the other four cyanide ions undergo rhodanese-catalyzed conversion to thiocyanate in the liver, with the thiocyanate undergoing renal elimination. Sodium nitrite 3% at 4mg/kg to 6 mg/kg can be administered over 3 to 5 minutes to promote the production of methemoglobin so that excess cyanide ions can be bound. Sodium nitrite does not induce vasoplegic syndrome and is used as a preservative of food.
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 chest pain. What is the MOST likely reason for her new onset cough?
A. Labetalol
B. Lisinopril
C. Losartan
D. Levemir
Correct Answer: B – Lisinopril
Rationale: Nagelhout page 179: “Angiotensin-Converting Enzyme Inhibitor (ACEI) are widely prescribed for the treatment of hypertension, angina, diabetic neuropathy, CHF, and in the management of the postmyocardial infarction patient. Adverse effects with the ACE inhibitors include cough, angioedema, renal failure, hyperkalemia, neutropenia, and proteinuria.The dry cough resulting from the ACE inhibitors occurs in up to 25% of patients and is the most common reason for discontinuation of the drug.”We learned in Pharm II that the adverse effect of coughing is more prevalent in females than it is in males. Labetalol is a Beta Blocker, Losartan is an ARB (Angiotensin Receptor Blocker), and Levemir is insulin. Of all the drugs listed, the only ACEI is Lisinopril.
Little Johnny is now a 58 year old patient who is admitted to your hospital with headache, lethargy, AMS that’s now progressed to Little Johnny being obtunded. After a head CT Little Johnny has been diagnosed with a ruptured cerebral aneurysm and is coming to your OR for emergency neurosurgery. Which CCB would you expect to be used for Little Johnny?
A. Verapamil
B. Amlodipine
C. Diltiazem
D. Nimodipine
Correct Answer: D – Nimodipine
Rationale: Nimodipine has been a long-standing treatment for treatment of cerebral vasospasm associated with neurologic emergencies such as ruptured aneurisms and neurosurgery. Nagelhout, 6thedition, pg 178, under Calcium Channel Blockers.
During Ms. Tooth Fairy’s preoperative assessment, the SRNA asks her about her current allergies. Ms. Tooth Fairy reported having a non-productive cough that developed after the initiation of the Lisinopril therapy. After noting this adverse reaction in her chart, the SRNA asks Ms. Tooth Fairy what medication she is now using to control her blood pressure. The prudent SRNA can expect Ms. Tooth Fairy to most likely be prescribed to what medication? (choose 3)
A. Captopril B. Losartan C. Olmesartan D. Atenolol E. Valsartan
Correct Answers: B, C, D
Rationale: Adverse effects associated with the ACE inhibitors include cough, angioedema, renal failure, hyperkalemia, neutropenia, and proteinuria. The dry cough resulting from the ACE inhibitors occurs in up to 25% of patients, and is the most common reason for discontinuation of the drug. If an ACE inhibitor cannot be tolerated, an angiotensin receptor blocker is substituted. The reason for the cough has been determined, as ACE is also responsible for the metabolism of bradykinin, which is blocked by these drugs. The resulting buildup of bradykinin contributes to the cough.
Nagelhout, JJ. Plause,KL. (2018).Nurse Anesthesia 6thEd.Philadelphia: Elsevier.p. 179
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?
A. IV Sodium Nitroprussideinfusion 12 mcg/kg/min
B. Sublingual Nitroglycerin 3 mg
C. IV Hydralazine2.5-20mg
D. IV Labetalol40 mg
Correct Answer: C
Rationale: Hydralazine is used for hypertensive episodes in pregnancy. “A” is incorrect because the max dose of Nipride is 10 mcg/kg/min. “B” is not the best choice because sublingualNitroglycerin is typically used for chest pain and the dose is incorrect (should be 0.3, not 3 mg). “D” is incorrect because the dose is too high to start with, and the patient’s heart rate is 60 so Labetalol will likely cause her to become bradycardic.
Reference: Nagelhout6th edition (hard copy). Page 178. Last sentence under the heading “Hydralazine”.
Mr. Johnson is a 70-year-old male that is coming in to have knee surgery. His history includes hypertension, diabetes type 2, and GERD. You see in his chart that he is taking a beta blocker at home, but when asked Mr. Johnson states that he did not take his beta blocker this morning. His current vitals include: HR 90, BP 165/87, RR 12, SpO2 99%. After inducing the patient his blood pressure is now at 184/95. The astute SRNA knows that which of the following drugs will be BEST to decrease preload and lower cardiac filling pressures?
A. Hydralazine
B. Phenylephrine
C. Atropine
D. Nitroglycerin
Correct Answer: D – Nitroglycerin
Rationale: Nitroglycerine causes venodilation, with an increase in venous capacitance, and a resultant decrease in preload. This results in a lowering of cardiac filling pressures, a lessening of myocardial wall tension, and ultimately a decrease in myocardial oxygen requirements.
Nagelhout Ch. 13 pg 178
A 26 year old parturient patient is being brought to the OR for conversion to a cesarean section after 18 hrs of a failed vaginal delivery. The patient has an epidural from early that morning that has not been working effectively. After trying to re-bolus the patient and increase the dose multiple times earlier in the day it is determined that the epidural is not suitable for the procedure and the decision is made to put the patient to sleep. Shortly after induction the patient’s vital signs are as follows. BP 210/120, HR 52, Sats 98%, resp 12, temp 97.2. The patient’s hepatic and renal function are normal. The astute SRNA understands that the following is the best treatment for this patient’s condition.
A. 10 mg of Labetalol
B. 5 mg of Metoprolol
C. Glycopyrrolate 0.2 mg followed by 5 mg of Labetalol
D. Glycopyrrolate 0.2 mg followed by 3 mg of Propanolol
E. No intervention is necessary
Correct Answer: C - Glycopyrrolate 0.2 mg followed by 5 mg of Labetalol
Rationale: Because labetalol provides both β- and α-blockade,an adequate heart rate must be present before labetalol can be used in the acute management of hypertension. It is recommended for hypertensive episodes in obstetric patients. Uterine blood flow is not affected in obstetric patients, even in the event of a dramatic decrease in systemic blood pressure.62 Labetalol undergoes hepatic metabolism and renal elimination.
Naglehout 5thedition, Chapter 13 Autonomic & Cardiac Pharmacology - page 196 (Anesthetic Uses – Metoprolol, Esmolol and Labetalol)
Mr. Jones has been on Sodium Nitroprusside 550 mcg/kg going at 4mcg/kg/min for 6 hours now. His baseline HR was 68 bpm and has now risen to 105 bpm. His Blood gas reads pH: 7.28, CO2: 37, HCO3: 19. Considering these findings, what is the BEST next step?
A. Increase the dosage of Nipride to 600 mcg/kg.
B. Discontinue the infusion and administer O2
C. Administer Methylene blue 5-6 mg/kg
D. Give 0.4 mg of Robinul.
Correct Answer: B – Discontinue the infusion and administer O2
Rationale: “In general, when more than 500 mcg/kg given faster than 2 mcg/kg/min, cyanide is generated faster than the patient can eliminate it. Clinically the development of metabolic acidosis, increased mixed venous oxygen content, tachycardia, and tachyphylaxis during sodium nitroprusside use are signs of cyanide toxicity. Treatment consist of discontinuing the sodium nitroprusside infusion, administering oxygen, and treating metabolic acidosis. Methylene blue at 1mg/kg to 2mg/kg may also be useful.” (Nagelhout, Ch. 13, pg. 177-178).
Mrs. Jones is on the operating table undergoing a hysterectomy. During the preoperative interview, she informed the nurse that she has not taken her blood pressure medication in several days, but that it usually runs around 118/72 at home. The CRNA has increased the flow of anesthetic gas, but her blood pressure remains 196/85 with a heart rate of 64 bpm. The CRNA decides to treat her blood pressure with 4mg of Hydralazine. The next blood pressure reading 5 minutes later is 178/80 with a heart rate of 91. What is the BEST action for the CRNA to take next?
A. Give another dose of Hydralazine 4mg now
B. Treat elevated HR and elevated blood pressure with a beta-antagonist, such as esmolol
C. Give a 500 ml fluid bolus
D. Wait for the next blood pressure reading before making a decision to treat.
Correct Answer: NO correct answer was given.
Rationale: Hydralazine causes direct relaxation of arterial smooth muscle. It can be administered intravenously for the control of hypertension in doses ranging from 2.5 mg to 20 mg.Tachycardiafrequently accompanies the decrease in blood pressure, secondary to the preferential reduction in afterload. It is important to remember that the onset of action can occur from2 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.
Nagelhout ebook pg. 178
A patient comes in for a scheduled laparoscopicrepair of an incisionalhernia. The patient has a history of COPD, orthostatichypotension, GERD, and Parkinson’s disease. As you prepare for the case, you notice that the patient is taking levodopa and tolcaponefor the treatment of Parkinson’s disease. Which medication, if needed during the case, would you reduce the dose of?
A. Methylene Blue B. Vasopressin C. Pantoprazole D. Norepinephrine E. Diphenhydramine
Correct Answer: D – Norepinephrine
Rationale: Tolcapone (Tasmar) and entacapone (Comtan) are used for the treatment of Parkinson’s disease as an adjunct to levodopa or carbidopa therapy. A third drug nebicapone is in clinical tri- als. They are selective and reversible inhibitors of catechol-O- methyltransferase (COMT). They enhance the action of levodopa and produce less fluctuation in drug response. There are concerns that COMT inhibitors may interact with various cardiac drugs by reducing their metabolism. Caution should be taken when admin- istering such drugs as isoproterenol, dobutamine, dopamine, nor- epinephrine, and epinephrine. Reduced doses should be started initially until the response can be assessed.
Nagelhout, J. J., & Elisha, S. (2018). CATECHOL-O-METHYLTRANSFERASE INHIBITORS. In Nurse anesthesia (5th ed., p. 202). St. Louis, MO: Elsevier.
A patient who is chronically on digoxin for the treatment of CHF accidentally receives an additional dose of digoxin during surgery. The patient’s EKG starts showing intermittent PVCs and then goes into Sick Sinus Syndrome. What medication would you NOT use to treat this patient?
A. Glycopyrrolate B. Epinephrine C. Atropine D. Calcium chloride E. Magnesium sulfate
Correct Answer: D – Calcium chloride
Rationale: (Nagelhout pg. 180-181)
“The mechanism of action of digitalis (1) Sodium potassium ATPase is inhibited resulting in increased intracellular sodium; (2) increased intracellular sodium produces a decrease in the exchange of sodium and calcium; (3) intracellular calcium increases; and (4) muscle contraction is enhanced.”
“Calcium administration is contraindicated in digoxin treated patients because it may lead to cardiac arrest. Preoperatively, in select patients, the serum levels of potassium and digitalis can be monitored.”
When intracellular calcium levels are already high, the extra dose of digoxin created digoxin toxicity which creates an even more increase in calcium influx further enhances the digoxin toxicity effects. Treating this patient with calcium chloride will increase the risk of other serious arrhythmias and possible cardiac arrest.
The metabolism of which of the following hypotensive agents is most likely to be affected in patients with severe renal disease?
A.Esmolol
B. Hydralazine
C Nitroglycerin
D. Nitroprusside
Correct Answer: D – Nitroprusside
Rationale: Nitroprusside contains 5 cyanide ions in chemical structure, and which are released upon metabolism by plasma hemoglobin.1 cyanide ion binds methemoglobin to form cyanmethemoglobin, whereas the other 4 cyanide ions undergo rhodanese-catalyzed conversion to thiocyanate in the liver, with the thiocyanate undergoing renal elimination (Nagelhout pg. 177).Hydralazine is metabolized in the liver and Nitroglycerin is extensively metabolized in the liver (Nagelhout, pg. 178).Esmolol is cleared in the plasma and tissues via ester hydrolysis that is independent of renal and hepatic function (pg. 17 Flood).Table 19-1 pg. 479 (Flood)
In regard to cyanide toxicity, the astute SRNA would correctly identify that the administration of sodium nitrite 3% will induce _________ which facilitates binding of excess cyanide ions.
A. Rhodanese-catalyzed conversion
B. Methemoglobinemia
C. Vasoplegic syndrome
D. Erythrocyte preservation
Correct Answer: NO correct answer was given.
Rationale: The chemical structure of sodium nitroprusside contains five cyanide ions, which are released upon metabolism by plasma hemoglobin. One cyanide ion binds methemoglobin to form cyanmethemoglobin, whereas the other four cyanide ions undergo rhodanese-catalyzed conversion to thiocyanate in the liver, with the thiocyanate undergoing renal elimination. Sodium nitrite 3% at 4mg/kg to 6 mg/kg can be administered over 3 to 5 minutes to promote the production of methemoglobin so that excess cyanide ions can be bound. Sodium nitrite does not induce vasoplegic syndrome and is used as a preservative of food.
Nagelhout Pg. 178
A 24 year old parturient presents to the OR for a cholecystectomy after having continuous right upper quadrant pain and N/V/D for the last 6 days. Once the patient arrives to the OR, the patient complains of severe salivation with a heart rate of 58. The pre-op nurse had an emergency and forgot to administerany pre-op medications! An astute SRNA knows that due to its quaternaryammonium structure, a safe medication to administer the parturientincludes __________?
A. Scopolamine
B. Fentanyl
C. Glycopyrrolate
D. Atropine
Correct Answer: C – Glycopyrrolate
Rationale: Glycopyrrolate - It is known for its excellent antisialagogueeffect without significant increase in tachycardia and due to its quaternary ammonium structure, it does not cross the BBB to significant degrees. Thus, CNS effects are not seen and makes it a great choice in obstetrics because it does not cross the placental barrier. Scopolamine(anticholinergic), although it has great antisialagogue effects,is not correct because it is a belladona alkaloid tertiary amine that causes CNS effects (crosses the BBB) including sedations, amnesia, mydriasis, cycloplegia. Fentanyl(opioid) is not correct due to it also crossing the BBB and can cause respiratory depression in the neonate. Atropine (anticholinergic) is not correct because it to like scopolamineis a belladonna alkaloid tertiary amine that freely crosses the BBB and may result in transient bradycardia during onset when low doses are given.
Nagelhoutpages 175-176
Sodium Nitroprusside
Nitroglycerin
Hydralazine
Match to:
A. Primarily Arterial Relaxation
B. Greater effect on Venous Relaxation
C. Venous & Arterial Relaxation
Sodium Nitroprusside: produces arterial and venous relaxation
Nitroglycerin: greater effect on venous than arterial relaxation
Hydralazine: primarily arterial relaxation
Sodium Nitroprusside: C
Nitroglycerin: B
Hydralazine: A
MOA of:
Sodium Nitroprusside
Nitroglycerin
Hydralazine
MOA of all 3 agents is believed to be primarily an induced increase in the concentration of vascular nitric oxide (not confirmed with hydralazine)
Sodium Nitroprusside:
Onset?
Duration?
Sodium Nitroprusside:
Onset within seconds
Duration 1-3 minutes (3-5 minutes and 1-10 minutes)
How does Sodium Nitroprusside effect: Preload Afterload Cardiac filling pressures Stroke volume Cardiac output
How does Sodium Nitroprusside effect: Preload: Reduces Afterload: Reduces Cardiac filling pressures: Decreases Stroke volume: Increase Cardiac output: Increase
Using Nitroprusside contributes to a decreased in myocardial O2 consumption by?
Left ventricle volumes are decreased and diminished myocardial wall tension should contribute to a decrease in myocardial oxygen consumption
What is the starting dose of Sodium Nitroprusside
0.3 mcg/kg/min an titrated until a response occurs
Infusion rates of __________ is rarely exceeded when using Sodium Nitroprusside
3 mcg/kg/min
A top infusion rater of 3 mcg/kg/min is rarely exceeded when using Sodium Nitroprusside. However young, normotensive patients may require up to __________
5 mcg/kg/min
Maximum recommended infusion rate of Sodium Nitroprusside is
10 mcg/kg/min
How is Sodium Nitroprusside Reconstituted?
Reconstitute 50 mg by adding 2—3 ml of D5W injection. Further dilute in 250, 500, or 1000 ml of D5W injection to provide concentrations of 200, 100, or 50 mcg/ml, respectively.
The solution should be discarded after 24 hours.
The chemical structure of sodium nitroprusside contains how many cyanide ions? When are they released?
The chemical structure of sodium nitroprusside contains five cyanide ions, which are released upon metabolism by plasma hemoglobin
One cyanide ion binds with _________ to form cyanmethemoglobine
methemoglobin
One cyanide ion binds with methemoglobin to form cyanmethemoglobin, whereas the other 4 cyanide ions undergo rhodanese-catalyzed conversion to __________ in the __________
thiocyanate in the Liver
One cyanide ion binds with methemoglobin to form cyanmethemoglobin, whereas the other 4 cyanide ions undergo rhodanese-catalyzed conversion to thiocyanate in the liver, with the thiocyanate undergoing ___________elimination
RENAL
One cyanide ion binds with methemoglobin to form cyanmethemoglobin, whereas the other 4 cyanide ions undergo rhodanese-catalyzed conversion to thiocyanate in the liver, with the thiocyanate undergoing renal elimination. This conversion to thiocyanate requires the cofactor ______.
thiosulfate B12
One cyanide ion binds with methemoglobin to form cyanmethemoglobin, whereas the other 4 cyanide ions undergo rhodanese-catalyzed conversion to thiocyanate in the liver, with the thiocyanate undergoing renal elimination. This conversion to thiocyanate requires the cofactor thiosulfate B12. Cyanide toxicity results when ______________________
this metabolic pathway is quantitatively overwhelmed.
In general, when more than ____ of sodium nitroprusside is administered faster than __, cyanide is generated faster than the patient can eliminate it.
500 MCG/kg
2 MCG/kg/min
What are the signs/symptoms of cyanide toxicity with sodium nitroprusside?
- metabolic acidosis
- increased mixed venous oxygen content
- tachycardia
- tachyphylaxis during sodium nitroprusside
What are the treatments of cyanide toxicity
Stop the sodium nitroprusside
Administer oxygen
Treat metabolic acidosis
Sodium nitrite 3% at 4-6 mg/kg over 3-5 minutes to promote production of methemoglobin to bind excess cyanide ions
Sodium thiosulfate at 150-200 mg/kg over 14 min can be administered over 15 minutes and administered every 1 hours as needed
Vitamin B12
Hydroxycobalamin can be effective (man made B12)
Methylene blue at 1-2 mg/kg may be useful
A new prodrug sulfanegen sodium is being tested.
A new prodrug ______ is being tested to tx cyanide toxicity. it’s called:
sulfanegen sodium
