REVIEW Flashcards
22 questions: neuropsych(3), herbal (3), antiarryth(3), pharmdyn/kin(2), MH(2), resp(2), abx(2), hemdynam(2), math(2), Essay(1)
The volume of distribution (Vd) is the relationship between:
Administered dose and plasma concentration
a drug that is lipophilic has a ______ volume of distribution, requiring a ______ dose
larger, higher
a drug that is hydrophilic has a ______ volume of distribution, requiring a ______ dose
smaller, smaller
to maintain steady state in plasma the ______ must equal the rate of clearance
infusion rate/interval dosing
how many half-times are required to reach a steady state? what can decrease this?
5, administering a loading dose
which kinetic model describes the process that metabolizes a constant amount of drug per unit time
Zero order
which kinetic model describes the process that metabolizes a constant fraction of a drug per unit time?
first order
what occurs in phase 1?
Modification: oxidation, reduction, hydrolysis, de methylation
what occurs in phase II?
Conjugation
what occurs in phase 3?
Excretion
4 parts of pharmacokinetics
- Absorption
- Distribution
- Metabolism
- Excretion
What is down regulation?
When you’re on a medication for a long time, desensitizes/enzyme removal of protein molecule
What are the three phases of the multi compartment model?
Rapid distribution
Slow distribution
Terminal phase
Which medications are metabolized by zero order effects?
Aspire in, ethanol, phenytoin
what is the curve for medications of high efficacy?
Up and to the LEFT
What does the slope tell us in the dose-response curve?
number of receptors that are occupied to produce a clinical effect
Continuous administration of an agonist may cause ______ of the target receptors
down regulation
What is a partial agonist?
binds to and activates receptor but no as much as a full agonist/low efficacy
What is an inverse agonist?
binds at the same site as an agonist but produces an opposite effect (turns off receptor)
what’s the difference between clean-contaminated and contaminated?
major break in sterility, spillage/acute inflammation
What bacteria do beta lactams target?
gram positive and gram negative
What antibiotic is commonly prescribed for dental prophylaxis?
Penicillin
What antibiotic class can penetrate into joints and cross the placenta?
cephalosporins
what first generation cephalosporin is the best choice for preventing SSI?
Cefazolin
What generation of Cephalosporins treat MRSA?
5th
What antibiotic is frequently given for prostate biopsy?
Cefoxitin
What antibiotic class is best at treating ventilator associated pneumonia?
Carbapenems
What drug can penetrate CSF to treat meningitis?
Ceftriaxone
Why should carbapenems never be users for simple prophylaxis?
they’re the “heavy hitters” last antibiotic option to treat resistant bacteria
What is the antibiotic of choice for colorectal surgery?
cefazolin and metronidazole
What is the antibiotic of choice for appendectomy?
Cefotetan or Cefoxitin
Dosage for Cefazolin:
2 grams, >120 kg 3 grams
(T/F) Vanomycin is good for gram negative
FALSE (best for treating MRSA)
What is the target bacteria for flagyl?
Anaerobic gram negative
What antibiotic class has unique anti inflammatory effects?
Macrolides
Vancomycin dosage:
15-20mg/kg: 1 g, 1.5 g, 2g
what is an indication for a glycopeptide (vancomycin)?
BL allergy or MRSA outbreak
What antibiotic class has the highest occurance of resistance?
Macrolides
What is the antibiotic of choice in BL allergy?
Clindamycin/ vancomycin ONLY in MRSA
Clindamycin dosage:
900mg
what cannot be given with sulfonamides?
anticoagulants, methotrexate, sulfonylurea, and thizides
metronidazole dosage:
500mg
What bacteria does metronidazole treat?
Anaerobic gram negative and clostridium
Dosing for Gentamicin:
5mg/kg
Dosing for piperacillin-tazobactam (zosyn):
3.375
IM epinephrine dosage for anaphylaxis
0.01mg/kg OR 0.5mg max Q5-15min
1:1,000
IV Epinephrine Dose for Anaphylaxis:
50-100mcg over 1-10 minutes
1:10,000
What are the antibiotics of choice for urinary procedures?
cefazolin and cipro
What antibiotics are safe in pregnancy?
PCN and cephalosporins
What would happen if you gave succinylcholine to an individual with Muscular dystrophy?
Rhabdomyolysis and hyperkalemia
What two drug classes cause MH?
Halogenated anesthetics
depolarizing neuromuscular blockers
Dantrolene dosage:
2.5mg/kg Q5-10mins
What is Trismus?
a tight jaw that can still be opened. normal response to succinylcholine
Which drug is contraindicated in the management of MH?
Verapamil- CCB could lead to hyperkalemia when administered with dantrolene
dantrolene classification
muscle relaxant
Dantrolene side effects:
muscle weakness, venous irritation
What are dantrolenes 2 mechanisms of action?
reduces calcium release from the RyR1 receptor in skeletal myocyte
prevents calcium entry into the myocyte- reducing the stimulus for calcium-induced calcium release
When should Dantrolene administration STOP?
when hypermetabolic state stops.
if pt requires more than 20mg/kg reconsider diagnosis
What should dantrolene be reconstituted with?
60 mL sterile water
How much dantrolene is in each bottle?
20mg
How much bicarb should be given to correct metabolic acidosis r/t MH?
1-2 mEq/kg IV
What is the max dantrolene dosage?
10mg/kg
what is the half life of dantrolene?
6-8 hours/ metabolized into active form in liver then excreted by kidneys
what is the half life of dantrolene?
6-8 hours/ metabolized into active form in liver then excreted by kidneys
how do we maintain UOP during an MH crisis?
- iv fluids
- mannitol 0.25g/kg
- furosemide 1mg/kg
what is calcium dosage for MH?
Ca Cl: 0.5-1g
Calcium Gluc: 1.3-5g
How long should dantrolene be continued after an MH crisis?
1mg/kg Q4-6H for 24H
Which three IV anesthetics have a favorable influence on bronchomotor tone?
propofol
ketamine
midazolam
Which two volatile anesthetics do NOT reduce bronchomotor tone?
desflurane and nitrous oxide
which three volatile anesthetics have a favorable effect on bronchomotor tone?
isoflurane
sevoflurane
halothane
What occurs when M3 receptors are activated?
bronchoconstriction
How long do short acting beta 2 agonists last? (according to stoelting)
4-6 hours
T/F long acting beta agonists should be prescribed if short acting beta agonists are used greater than twice a week
TRUE
how does a beta agonist work?
causes stimulators G protein to activate adenylate cyclades converting adenosine triphophate into cyclic adenosine mono phosphate (cAMP) which decreased calcium and leads to smooth muscle relaxation
what are the most common side effects of a beta 2 agonist?
tremors, tachycardia, hyperglycemia, hypokalemia, and hypomagnesmia
What is ipratropium?
short acting anti cholinergic commonly used as maintenance therapy for COPD
What is tiotropium?
the ONLY long acting anti cholinergic available for COPD (M3 receptor)
What are common side effects of anti cholinergics?
dry mouth, urinary retention, constipation, pupillary dilation, and blurred vision
can’t see, can’t pee, can’t spit, can’t shit
What is fluticasone?
inhaled corticosteroid
what is montlukast?
leukotriene modifiers
What is cromolyn?
mast cell stabilizer
What is theophylline?
methylxanthine
What is an additional measure that can be taken, last resort to cause broncodialation?
Magnesium
What is an undesired side effect of ketamine?
increase in salivation
How does nitric oxide work?
non cholinergic PNS nerves release onto airway smooth muscle which causes relaxation; thus, broncodilation
copd treatment:
education/smoking cessation
short acting bronchodialators
long acting bronchodialators
rehab
inhaled steroids
oxygen
surgery
clinical manifestations of asthma:
expiratory wheezing, dyspnea, non productive cough, prolonged expiration, tachycardia, tachypnea
An asthma attack can lead to:
status asthmaticus which is a bronchospasm not reversed by usual measures
What are the 4 histamine releasing medications that should be avoided in patients with bronchoconstricting diseases?
atracurium, succs, morphine, merderidine
What is the beta blocker of CHOICE for individuals with lung disease?
Esmolol (beta1 selective)
asthma management:
SABA
ICS
LABA
Theophylline
daily systemic steroid
How do inhaled steroids work?
stabilize mast cells by preventing degranulation + production of cytokines
Albuteral dose:
nebulized 2.5mg OR 90mcg/puff 2-3 puff
When should inhalers be d/c’ed and continued after surgery?
they should be continued the morning of and be restarted immediately
What is the LABA black box warning?
can cause fatal or near fatal asthma attacks when NOT used in conjunction with a SABA
when should methylxanthine be discontinued prior to surgery?
the evening before
What is an anesthesia specific consideration for methylxanthine?
check a serum level
Methylxanthine side effects:
> 20mcg/ml: n/v, diarrhea, headache, sleep disturbances
30mcg/ml: seizures, tachy dysrhythmias, CHF
Ipratropium dose:
200unit/inhal 2 puffs QID
Which surgery necessitates pretreating with anticholinergics?
Gi surgery: large amount of vagal stimulation
What is the MOA of leukotriene modifiers?
inhibits 5-lipoxygenase enzyme- decrease leukotriene synthesis which decreases bronchospasm, vasoconstriction, eosinophil recruitment
T/F montelukast is used in the management of acute bronchospasm
FALSE
When should we stop giving albuterol when pt has ETT present?
when tachycardia occurs
What is our first step to breaking a bronchospasm?
increase volatile gas bc it is PNS innervation
When should supplements be discontinued prior to surgery?
at least two weeks
What herbal supplement most commonly causes coagulopathies?
Gingko
What are the effects of Dong quai on platlets?
decreases activation
What is echinachea used for?
Treats viral, bacterial, and fungal URIs by modulating cytokine signaling and stimulation of macrophages and NK cells
Treats chronic wounds and arthritis
Long term use: acute rejection due to immunesupp
What can occur with ephedra use in combination with an MAOI?
life threatening hypertension, hyperpyrexia, and coma
Can feverfew be taken by an individual also taking warfarin?
no, it inhibits platelet activity
What is the indication for Gingko biloba?
neuroprotective: treats alzheimers, memory loss, and multi infarct dementia
Peripheral vascular disease- decreases blood viscosity
What two drugs interact with gingko?
NSAIDs, and anticoagulants
How does long term kava use affect anesthetic dose?
increases dose requirement
What are adverse effects of kava?
increase effects of ETOH, barbiturates, and other drugs
can prolong anesthetic agents
kava dermopathy- scaly cutaneous lesions
How does St. Johns wort affect anesthesia?
can delay emergence
What is valerian root?
herb used for anxiolytic, restlessness, and sleep aids
Gi upset, headache, tremor, cardiac disturbances
Can potentiate effects of benzos
What type of drug interacts with turmeric?
antacid medications such as PPIs and H2A
What supplements are hepatotoxic?
Echinacea, ephedra, saw palmetto, garcinia
immunosuppressive vs immunostimulating
echinacea (long term use suppresses)
echinacea, garlic, st john wort, ginseng, garcinia
Which 5 supplements can cause delayed emergence?
St. John wort, Valerian root, Kava, ginger, saw palmetto
What 3 supplements DO NOT increase bleeding risk? all other supplements do
increase clotting: St. John’s wort, garcinia
no effect: ephedra
What is the first drug given for an initial seizure intraoperatively?
Benzodiazepine
After seizure has stopped, what drug is most commonly given after a Benzodiazepine?
Keppra 1000-3000mg
T/F gabapentin should be discontinued a week prior to surgery
False, should be continued until preoperative setting
(if d/c indicated, should do 1 week taper due to potential for withdrawal)
Should ANY seizure medications be d/c’ed prior to surgery?
NO, could cause a seizure to occur
What are indications for Keppra?
epilepsy, seizures, neurosurgery- brain tumor removals
Which AEDs cause the need for higher doses of anesthetic drugs?
Tegretol, Phenytoin
Does phenytoin undergo first order or zero order kinetics?
first at <10mcg/mL
zero at >10mcg/mL
What AED causes upregulation of acetylcholine receptors and what does that cause?
Phenytoin, effects NDMB and DMB: can cause release of high levels of potassium or greater response to succs
What is the dose for midazolam?
2.5-5mg/IV (up to 15mg for status epilepticus)
How should status epilepticus be managed?
upper airway management, O2
IV access, benzo, AED drug
Do ketamine and propofol increase or decrease the risk of seizure?
increase, can actually mimic seizure like phenomenon
What are the effects of benzos and barbs on AEDs?
interactive, decreasing metabolism
How does ethanol affect volatile agents?
volatiles must compete with the same GABA receptors as ethanol, competitive inhibition
Serotonin: head, red, fed
Head: satisfaction, sociality, migraine, decreased anxiety, impulsivity, sex
Red: inhibits platelets and bleeding
Fed: Gi motility, naused
How long do SSRIs take to work?
4-6 weeks
d/c causes brain zap
What are the cardiac symptoms that occur with TCA’s?
Wide QRS complex
What is the DOPAMINE mnemonic?
Drive
psychOsis
Parkinsonism
Attention
Motor
Inhibition of prolactin
Narcotics
Extrapyramidal
_____ generation antipsychotics normally have _____ side effects while _____ generations normally have _____ side effects
first, neurological; second, metabolic
What is given to treat acute muscular dystonia from antipsychotics?
Benadryl 50mg
What is Neuroleptic Malignant Syndrome and the S/S associated with it?
Occurs with recent antipsychotic use: can mimic MH
S/S: confusion
agitation
hyperthermia
muscular rigidity
seizures
TX: dantrolene
What antipsychotic can cause Diabetes insipidus?
lithium
What drug increases requirement of non-depolarizing paralytic doses?
keppra, levetiracetam
What drugs should be avoided in patients taking cocaine or amphetamines?
ketamine, ephedrine, and catecholamines
What is the one thing that isnt present in patients with SS and NMS?
no CO2 changes
What are the effects of acute and chronic alcohol use on anesthesia requirements?
acute caused inhibition which decreases the need of medications
chronic causes induction which increases the amount of medication needed
What order kinetics with alcohol associated with?
zero order kinetics- high risk of toxicity
What drugs should not be given to individuals who use cannabis?
ketamine, atropine, epinephrine
What are major anesthesia considerations of Cannabis ?
Coronary artery spasm with CAD, increased airway reactivity
What are some anesthesia considerations for patients on antipsychotics?
post op confusion
hypotension
impaired temp regulation
What drugs should not be given to an individual taking MAOIs or TCAs?
no ephedrine or ketamine
only low doses of direct acting sympathomimetics to prevent a hypertensive crisis event
What psych meds cause a risk for developing serotonin syndrome when combined with opioids?
high risk: MAOIs OR previous serotonin toxicity
low/intermediate risk: SSRIs, SNRIs, TCAs, St John wort, lithium
Which opioids can cause development of serotonin syndrome in patients taking some psych meds?
low risk: morphine, codeine, oxycodone, hydromorphone, oxymorphone, and buprenorphine
medium risk: fentanyl, tapentadol, and methadone
high risk: tramadol, meperidine, dextromethorphan
What are the two neuro syndromes that can look like MH?
Serotonin syndrome and neurological malignant syndrome
When before surgery should MAOIs be stopped?
2 weeks (irreversible) - 1 day (reversible)
What is second line therapy for seizures?
levetiracetam (keppra) 1000-3000mg
phenytoin
valproic acid
first line = benzos
Should mood stabilizers be d/ced prior to surgery in individuals with hx of suicidal ideations?
gray area… it would be best to…. but what if the attempted suicide due to that? some people recommend continuing the med and using major caution in the anesthetic plan.
stopped 24H prior to surgery
What 2 Na channel blockers lengthens AP?
procanimide
flecinide
What NA. channel blocker shortens AP?
Lidocaine
How do Class 1 antiarrythmic medications work? (lidocaine, procanimide, flecainide)
lengthens AP and Phase 0 depolarization to decrease conduction speed (lidocaine shortens AP)
Sympathomimetics:
Natural catecholamines:
Epinephrine
Norepinephrine
Dopamine
Synthetic catecholamines:
Isoproterenol
Dobutamine
synthetic noncatecholamines:
Ephedrine
Phenylephrine
What antiarrythmic increases pacemaker capture threshold?
Flecainide
What is the beta blocker of choice to treat tachycardia perioperatively?
esmolol OR labetalol for tachycardia & HYPERTENSION
What are the three mechanisms that remove neurotransmitters from the synaptic cleft?
- Uptake into presynaptic terminals
- Extraneural uptake
- Diffusion
What is the dose of isoproterenol and what is it best at treating?
1-5mcg/min Heart block
What are the effects of ephedrine?
direct: binds to alpha and beta receptors
indirect: inhibits neuronal norepinephrine reuptake and displaces more norepinephrine from storage vesicles
How does phenylephrine work and what is the dosage?
alpha1 receptors, primarily venoconstriction 50-200mcg bolus
reflex bradycardia
What occurs in phase 0 of the cardiac cycle?
NA channels lead to depolarization of the cell
How do NON dihydropyridine CCBs work?
block calcium channels in heart muscle, reduce Ca in cardiac cells, leading to a decrease in the heart rate and contractions DILTIAZAM
How do dihyrdopyridine CCBs work?
bind to calcium channels on vascular smooth muscle, promoting vasodilation NICARDIPINE
What three things cause arrhythmias to occur?
- reentry
- enhanced automaticity
- triggered
how to potassium channel blockers work?
prolong repolarization and duration of the AP/refractory period
What cardiac phase do class I antiarrythmics work on?
phase 0 depolarization
+ lidocaine phase 4
what classes of antiarrythmics treat wide complex tachycardias?
IC and III
What does flecainide treat?
ventricular and atrial/reenty arrythmias such as WPWS
What antiarrythmic class prevents the risk of sudden cardiac dealth?
Beta blockers
What cardiac phase do class IV antiarrythmias work in?
Phase 2 contraction
What drug should never be given to a patient with WPWS and why?
Diltiazem, enhances conduction of accessory pathways
What antiarrythmic can alter thyroid function and why?
amiodarone, high percentage of iodine in the molecule
What is the pneumotic that helps us remember antiarrythmic classes?
Some (sodium blockers)
block (beta blockers)
Potassium (potassium blockers)
Channels (calcium blockers)
Calcium channel blockers are a ________ inotrope and should not be used in patients with ______ heart failure
negative, systolic
What is the preferred treatment for WPWS?
procanimide
What is the preferred treatment for WPWS?
procanimide
What phases of the cardiac cycle are effected by class III antiarrythmics?
Phase 1 and 3
Where do class IV antiarrythmics work in the cardiac cycle?
mostly phase 2
phase 4 in pacemaker cells
where do class II antiarrythmics work in the cardiac cell?
Phase 4, pacemaker
phase 2, myocyte
What phase of the cardiac cycle do class 1 antiarrythmics work on?
Phase 0 in nonpacemaker
How does lidocaine work since it shortens AP while other sodium channel blockers lengthen the AP?
works on the conduction by decreasing conduction in the SA node to allow AV node to become the primary pacemaker at a lower rate
