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Pharmacology 514 > Special Populations (Geriatric, Obese, Pediatric, Cancer) > Flashcards

Special Populations (Geriatric, Obese, Pediatric, Cancer) Flashcards

1
Q

What is important to note about the organ function of aged patients?

A

They have less organ reserve, and the organs cannot take as much stress induced by drugs, surgery, and hypoxia

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2
Q

How do body water percentages vary between Young Adults (20-30) and older adults (60-80)? Lean Body mass? Body fat? Serum Albumin? Kidney weight? Hepatic blood flow?

A

Water %, Young = 60% Older = 53%
Lean body mass, Young = 19% Older = 12%
Body fat, Young = men18-20, women=26-33
Serum Albumin, Young=4.7 Older = 3.8
Kidney weight, Young = 100% Older = 80%
Hepatic flow, Young = 100% Older = 55-60%

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3
Q

What is the significance in the change of body fat composition of the elderly?

A

It impacts the compartments that our drugs go to. Lipid soluble drugs will stick around longer.

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4
Q

Do the elderly require a special anesthetic plan?

A

No, but meticulous preoperative assessment should be performed as well as detailed management of intraoperative variables and disease states. Use cautious titration of drug administration and dosages. (be less reactive to changes, or you will chase your vitals the whole case)

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5
Q

What is the mechanisms for producing age-related increases in pharmacodynamic sensitivity to anesthesia agents in the elderly?

A

It is unknown, but could result from declining neuronal function (oxidative stress and mitochondrial genetic mutations).

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6
Q

What do studies suggest are the most significant age-related dose factors for reducing IV medications for the elderly?

A

Longer Half-lives, 30% decrease dose/ 10 years, Increased brain sensitivity to narcotics, plasma drug concentrations immediately after injection are usually higher in elderly (give less).

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7
Q

What are possible complications for optimizing postoperative pain management in the elderly?

A

If they have preexisting cognitive impairment or fear of opioid related side effects. (Opioid requirements are inversely related to patients age and essentially independent of body size.)

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8
Q

How should regional anesthesia be handled in the elderly as far as dosing requirements?

A

With a fixed dose and volume of local anesthetic, the sensory level of a block is higher in the elderly. So use a smaller volume. Segmental dosing of epidurals are similarly reduced with aging.

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9
Q

What are the anesthetic implications for dosing NMBA’s in the elderly?

A

Elderly have less skeletal muscle mass
Neurogenic atrophy of the neuromuscular junction allows for proliferation of extra-junctional cholinoreceptors. Increased density of receptors at the muscle endplate necessitates the need for greater concentrations of NMB drugs (ED50 higher) - but still give less, it will just take longer for it to work.
Maximal effect is delayed. Duration of action extended (metabolism/elimination).

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10
Q

How should antagonism for NMBA’s be changed for the elderly?

A

It will remain unchanged.

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11
Q

What is one of the most common post operative complications with the elderly?

A

Emergence Delirium

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12
Q

What monitor may help reduce emergence delirium?

A

The BIS. It will allow for the least anesthetic possible during the surgery which will decrease chances of post operative delirium.

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13
Q

Which medications may induce post op delirium?

A

Anticholinergics, corticosteroids, meperidine, hypnotics

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14
Q

The chances for emergence delirium are increased when using more than how many medications?

A

5 or more

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15
Q

Which type of anesthesia should be considered to avoid emergence delirium?

A

Regional, for intraop and postoperative pain control.

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16
Q

Older patients who are not a threat for personal harm should not be prescribed these two types of medication. Nor should they be first line when the patient is one who may be a threat.

A

Antipsychotics and Benzos. Benzos should not be used as a first line treatment when the patient does have these issues. Prescribers should use the lowest effective doses of Benzos and Antipsychotics for the shortest duration and only after behavioral interventions have failed.

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17
Q

The pharmacology of obese patients is significantly influenced by?

A

Difference in tissue distribution, hemodynamics, blood flow to tissue types (organs, adipose, splanchnic), plasma composition, kidney and liver function

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18
Q

The pharmacokinetic factors of obese patients is significantly influenced by?

A

Lipid solubility of the drug, diffusion through body compartments

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19
Q

In general, what should dosing consider for obese patients?

A

Volume of distribution for loading dose, clearance for maintenance dose.

20
Q

When considering ideal body weight (IBW) versus total body weight (TBW), when should each be used?

A

IDB for drugs that are preferential to lean tissue.

TBW for drugs with equal distribution to lean and adipose tissue.

21
Q 
Should IBW or TBW be used for the following IV Anesthetic drugs in obese patients?
Thiopental
Propofol
Midazolam
Dexmedetomidine
A

Thiopental: IBW (somewhat increased) (Prolonged duration of action and 1/2 life)
Propofol: TBW (Highly lipophilic. Total clearance and VD correlate well with TBW)
Midazolam: Loading dose:TBW, Maintenance: IDW. Sedative effects correlate better to larger VD and less to elimination - higher dose to achieve initial therapeutic effect
Dex: TBW (Does not effect respiration. Preferred drug for analgesic qualities)

22
Q 
Should IBW or TBW be used for the following IV Muscle relaxants in obese patients?
Succs
Roc/Vec
Atracurium
Cisatracurium
A

Succs: TBW (Large extracellular fluid compartment in the obese. Psuedocholinesterase activity increase with weight)
Roc/Vec: IBW (Prolonged DOA with TBW administration (faster onset as well)
Atracurium: TBW (Organic independent elimination)
Cisatracurium: IBW (Similar kinetics to atracurium but increase DOA seen with TBW dosing.)

23
Q

Should IBW or TBW be used for the following IV Narcotic drugs in obese patients?
Fentanyl
Sufentanil
Remifentanil

A

Fent: Inconclusive (Dosing based on TBW overestimates dose requirements. Measure clearance has non linear relationship to TBW (implication to IBW))
Sufentanil: Loading TBW, Maint: IBW (Increased VD and prolonged elimination 1/2 life correlates with degree of obesity; clearance similar in all populations)
Remifent: IBW (Kinetics not effected by weight)

24
Q

T/F Converting adult doses to children’s doses on a per kilogram basis dose always yields equivalent drug concentrations or effects?

A

False. Not always. Children should not be viewed as small adults.

25
Q

Which factors pertaining to drug kinetics will change from fetus to baby to child to adult?

A

VD, drug elimination, receptor sensitivity, side effects, organ function

26
Q

What are drug administration options for peds?

A

Rectal, Intranasal, IM, IV

27
Q 
What are the kinetics and/or pros/cons/indications of the following administration techniques?
Rectal
Intranasal
IM
IV
A

Rectal: Generally a slower absorption; commonly used in children under 5 for sedation
Intranasal: Faster onset, less offensive to children: midaz and fent
IM: not recommended due to pain that last days; emergency drugs and pain medications
IV: Distribution dependent of circulating blood elements, Blood-tissue partition coefficients, distribution of blood flow

28
Q

Review: What is a requirement for a drug to cross the cell membrane and to be cleared?

A

The drug must be a nonbound water soluble drug in circulation. (This is what the notes say. But drugs need to be lipid soluble and non ionized to cross the cell membrane. Maybe he just meant for the clearance part?)

29
Q

What are the major proteins involved in binding drugs in children? And what is their prevalence in relation to adults and infants?

A

albumin and alpha1 acid glycoprotein. They have a much greater concentration in older children than in adults, and a much lower concentration in infants.

30
Q

What are some other substances that may displace drugs from proteins in infants, which can alter the pharmacology?

A

Billirubin

31
Q

Do agents that are poorly protein bound have an apparent larger or smaller volume of distribution in children?

A

An apparent larger VD (explains the larger VD in neonates)

32
Q

How does the much lower concentration of major proteins effect volatiles in infants?

A

It has implications for the blood-gas and blood-tissue coefficients.

33
Q

What receives the greatest blood flow in in pediatrics?

A

The central organs (brain, liver, heart, kidneys)

34
Q

Because there are relatively smaller muscle mass and greater fat stores in neonates and infants, what does this mean for water soluble drugs like Succs?

A

May require higher doses

35
Q

What is important to note about the BBB of peds?

A

The integrity of the blood-brain barrier is less than adults (not as well formed) so there is rapid uptake of anesthetics into the CNS and higher brain blood flow.

36
Q

Is pediatric receptor affinity and sensitivity different than adults?

A

Yes, the affinity and sensitivity for peds is increased

37
Q

What is important to note about hepatic and renal function from birth on?

A

There are many developmental changes with both. Changes in renal function (GFR at birth is 40 mL/minute, GFR at 1 year is 100 mL/min)

38
Q

What are the two primary questions the CRNA should be asking when dealing with cancer patients?

A

How will the chemotherapy drugs affect your patient and how will your anesthetic affect the patient’s prognosis

39
Q

What should we assume about all patients undergoing chemotherapy?

A

That they will have nausea and vomiting

40
Q

What should the CRNA focus on as far as effects of chemo drugs on the patient?

A

CV system, Pulmonary function, and Hematology

41
Q

What are some of the toxic effects that drugs like Cisplatin, Methotrexate, Bleomycin, Doxorrubicin, and Cetuximab have?

A

Nephrotoicity, peripheral neuropathy, nerve dysfunction, Myelosuppression with neutropenia and thrombocytopenia, Pulmonary fibrosis, Cardiotoxicity, Interstitial lung disease.

42
Q

Which drugs can suppress NK cell activity and can promote cancer cell metastasis?

A

Volatiles, barbs, and ketamine

43
Q

Which agent we use reduces purine and thus DNA synthesis and also suppresses neutrophil chemotaxis, potentially facilitating the spread of cancer?

A

Nitrous Oxide

44
Q

Which agent exhibits a protective effect through various mechanisms, including an anti-inflammatory effect, inhibition of COX-2 and reduction of PGE-2, weak B-adrenoreceptor binding, enhancement of anti-tumor immunity, and NK function?

A

Propofol

45
Q

What medicine may produce cellular and humoral immunosuppression in particular?

A

Perioperative opioids, specifically morphine

Pharmacology 514 (7 decks)

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