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TDRD Flashcards

1
Q

So What makes a drug an Ideal Agent?

A

Hypnosis and amnesia
Rapid onset and rapid metabolism to inactive metabolites
Minimal CV or respiratory depression
No histamine release, non-toxic, nonirritating
No untoward neurologic issues (seizures, myoclonus or neurotoxicity)
Good analgesic, antiemetic and cardio protective

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2
Q

5 rights

A

Right drug, patient, dose, route, time

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3
Q

Propofol (Diprivan)

A

Stimulation of GABA, highly lipid soluble
Uses: TIVA, induction, antiemetic qualities, outpatient surgery, endoscopy, MAC
Contraindicated in allergies to eggs, egg products, soybeans or soy products (?)
Pain on injection (Lidocaine: to mix or not to mix)
Can support bacteria
Good up to 12 hours in opened vial
Good for 6 hours after being drawn into a syringe
CV: decrease HR and BP, decreased SVR
Dose dependent respiratory depression
Minimal residual CNS effects
Decrease in CBF and ICP
Protein binding: 97% to 99%
Dosing:
1-2.5 mg/kg IV induction (2 mg); 25-200 mcq/kg/min sedation/maintenance
Pharmacodynamics
Onset: 30 sec
Duration: dose and rate dependent
Elderly:
More sensitive, prolonged effects possibly due to decreased CO and clearance
Children:
Large volume of distribution and quicker clearance (may need larger dose)
Obese:
Base dosing on lean body weight
Chronic Alcoholism? CV Disease?

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4
Q

Lidocaine

A

Dose: 0.5-1.5 mg/kg (adjusted dependent on the patient)
Older adults: 0.5-1 mg/kg

  • Hemodynamically unstable: keep less then .5mg/kg
  • Keep it on the lower side if they are less than 60 kg (?)

Administered to:

  • Suppress the coughing reflex during laryngoscopy and intubation
  • Reduce airway responsiveness to noxious stimuli
  • Reduces pain caused by IV injection agents

It might increase the hypotensive effects of sedative-hypnotic agents

Careful in cardiac patients

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5
Q

Ketamine (Ketalar)

A

Noncompetitive NMDA receptor antagonist that blocks glutamate
Stimulates SNS: inhibits the re-uptake of Norepinephrine, dissociative anesthetic
Indications: induction, sedation, CV collapse, sedation for mentally challenged, “bad” epidural/spinal
Effects:
Intense analgesia (review the opioid receptors)
CV: increase in BP, HR, CO, PAP, CVP, CI
Respiratory: minimal depression, maintains upper airway reflexes, increased oral secretions (Glyco), bronchodilator
Emergence delirium: low lights, quiet room, VERSED

Increases in ICP?
Phencyclidine derivative, hallucinogenic, use VERSED
Norketamine is an active metabolite, 1/3 to 1/5th as potent as Ketamine
Dosing
Induction: 1-2 mg/kg IV, 4-5 mg/kg IM, titrated for effect
In Low doses it can be opioid sparing
Pharmacodynamics
Onset: IV in 30 sec; IM in 2-4 min
Duration: 10-15 min (IV), 15-25 min (IM)

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6
Q

Can use Ketamine in Bronchospastic Patients

A

**Know it*

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7
Q

Thiopental (Pentathol)

A

Introduced in 1934
No longer available in the United States or elsewhere
Short acting barbiturate, activates GABA
Uses: Sedative, hypnotic, anticonvulsant, treatment of ICP (neuro cases), induction of anesthesia
Effects:
Hypotension
Decrease in CBP and ICP
May increase N/V
Some histamine release
500mg vial

Contraindicated in:
Acute Intermittent Porphyria or Variegate Porphyria
Status Asthmaticus
Protein Binding: 72%-86%
Avoid extravasation  necrosis
Dosing:
Induction: 3-5 mg/kg IV in adults
Pharmacodynamics
Onset: 30-60 sec
Duration: 5-30 min
Hepatic metabolism

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8
Q

Etomidate (Amidate)

A

Ultrashort-acting nonbarbiturate hypnotic, depresses RAS
Uses: induction, procedural sedation
Effects:
Minimal CV effects, decrease in CMR, CBF, ICP
Respiratory depression
Potential for increased N/V and pain on injection (per Dr. Havenstein and Crosse??????). WHY can it burn? glycerol
Myoclonic movements can be decreased with opioids
Temporary Adrenocortical suppression limits long-term use

Protein Binding: 76%
Dosing:
Induction: 0.2-0.3 mg/kg
Pharmacodynamics
Onset: 30-60 seconds
Hepatic enzyme and plasma esterase hydrolysis

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9
Q

Dexmedetomidine (Precedex)

A

Highly selective, potent central acting Alpha2 adrenergic agonist, results in inhibition of norepinephrine release
Uses: procedural sedation, analgesia, awake fiberoptic intubation, postop sedation, pediatrics
Effects:
Bradycardia, sinus arrest and hypotension (tx with atropine, ephedrine and volume)
Dose dependent analgesia, anxiolysis and sedation with minimal respiratory depression
Protein Binding: 94%
Dosing RANGES:
Procedural sedation: 0.5 -1 mcg/kg over 10 min: infusion .3-.7 mcg/kg/hour
Awake Fiberoptic intubation: 1 mcg/kg over 10 min: infusion 0.7 mcg/kg/hour until intubated
Pharmacodynamics
Onset: 5-10 min; peaks in 15-30 min
Duration: 60-120 min (dose dependent)
Hepatic metabolism
Urinary excretion

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10
Q

Methohexital (Brevital)

A

Rapid Ultrashort-acting barbiturate, enhances effects of GABA
Uses: ECT(gold standard), ENDO, very short procedures
Effects: deep sedation, skeletal muscle hyperactivity, pain on injection
Must be reconstituted into a 1% (10mg/cc) solution for intermittent IV use

Shortest acting barbiturate and does NOT have anticonvulsant activity (lowers the seizure threshold)
Great for Electroconvulsive Therapy
Pharmacodynamics
Dose: 1-1.5 mg/kg
Onset: < 1 min
Duration: 5-7 minutes
Hepatic metabolism
Urinary Excretion
RAPID redistribution

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11
Q

What are 3 ways to cause muscle relaxation?

A

Regional, neuromuscular blocker, inhalational anesthetic

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12
Q

Neuromuscular blockers listed

A

Depolarizing – succinylcholine (Anectine, SCH)

Nondepolarizing:
Rocuronium (Zemuron)
Vecuronium (Norcuron)
Pancuronium (Pavulon)
Benzylisoquinolines:
Mivacurium (Mivacron)
Atracurium (tracrium)
Cisatracurium (Nimbex)

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13
Q

Depolarizing Relaxant

A

Succinylcholine (suxamethonium, Quelicin, SCH or Anectine) (200mg - 20mg/ml)
Binds to 2 alpha subunits of nicotinic cholinergic receptors, allows sodium and calcium influx, potassium efflux, resulting depolarization of muscle
Remains depolarized until SCH diffuses away from receptor
Mimics action of Acetylcholine (AcH)
Uses: rapid muscle relaxation, routine intubation, very short cases, OB, RSI, Laryngospasm
What you should know about SUX!
Can cause Hyperkalemia
Triggering Agent for Malignant Hyperthermia
Minimal Histamine release
Decrease HR due to muscarinic stimulation
SCH apnea/Psuedocholinesterase Abnormality
Phase I normally
Phase II block from large or repeated doses
Fasciculation’s can cause muscle pain Postop
In children, increased risk of increased K and cardiac arrest from undiagnosed myopathies

Metabolism:
Butyrylcholinesterase (synthesized by the liver and found in the plasma) also called plasma cholinesterase
SCH diffuses away from the NMJ, hydrolyzed in the plasma by plasma cholinesterase
Decreased levels of pseudocholinesterase can prolong the block (pregnancy, liver disease)
Succinylmonochline is a weak active metabolite
Dosing:
1-1.5 mg/kg IV for rapid sequence, 2 mg/kg IV in smaller children, 3-5 mg/kg IM, 20 mg IV for laryngospasm
Onset: 30-60 sec IV, 2-5 min IM
Duration: < 10 min IV, 10-30 min IM

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14
Q

Drug errors? most common pic

A

Misc biggest category …Succinylcholine 17.1% , inhalational 13.2, opioids, local,

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15
Q

Malignant Hyperthermia

A

Succinylcholine, inhalational anesthetics - releases Ca++ - sarcoplasmic reticulum, Mutations in the RYR1 gene (ryanodine receptor)- increased ETCO2

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16
Q

Nondepolarizing Relaxants intro

A

Compete with/block Ach at the nicotinic receptor alpha subunits on motor endplate inhibiting depolarization
Uses: Muscle Relaxation for surgery, intubation
Aminosteroids
Primarily liver breakdown, kidney excretion, minimal histamine release, highly ionized at physiologic pH, small volume of distribution, limited lipid solubility
Potential for allergic reactions

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17
Q

Nondepolarizing Relaxants

Rocuronium (Zemuron)

A

Rocuronium (Zemuron) (50mg/100mg vials, 10mg/ml)
Intermediate action, rare histamine release, no effect of BP or HR, can be used to defasciculate with SUX
Dose:
0.6/1.2 mg/kg (higher dose for RSI and lower dose for routine intubation/surgical relaxation)
5 mg for defasciculating dose with SUX
Maintenance/Repeat dose of 0.1-0.2 mg/kg as needed
Pharmacodynamics
Onset: 1-2 min depending on dose
Duration: about 30 min
Eliminated primarily by the liver

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18
Q

Nondepolarizing Relaxants- Vecuronium

A

Vecuronium (Norcuron) (10mg 1mg/ml)
Intermediate NMB, no histamine release, cardiac stable, might precipitate with Thiopental
Dose:
Induction/intubation: 0.08-0.1 mg/kg
Pretreatment/priming with 10% of intubation dose Maintenance for surgical relaxation: 0.01 mg/kg
Pharmacodynamics
Onset: 2-3 min (good intubating conditions); 3-5 min (maximal blockade)

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19
Q

Nondepolarizing Relaxant- Pancuronium

A

Pancuronium (Pavulon) (10mg - 1mg/ml)
Long acting, no histamine release, modest tachycardia due to antimuscarinic stimulation, norepinephrine release and reduced uptake of norepinephrine by adrenergic nerves
Increase in BP, careful in any patient that will not tolerate increase HR and cardiac output
Dose:
Initial: .08-.12 mg/kg
Maintenance: 0.01 mg/kg
Pharmacodynamics
Onset: 2-3 min
Duration: 60-100 min

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20
Q

Benzylisoquinolines Intro

A

Hofmann Elimination
Ester hydrolysis
Plasma cholinesterase metabolism
Histamine release
Some changes to BP and HR

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21
Q

Hofmann Elimination

A

Spontaneous, non-enzymatic, non-organ dependent chemical breakdown at physiologic temperature and pH
Temperature increase and pH increases……. Increased metabolism
Temperature decreases and pH decreases……. Decreased metabolism

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22
Q

Benzylisoquinolines- Mivacurium (Mivacron)

A

10mg/20mg vial 2mg/ml -

HISTAMINE RELEASE when given quickly
Spontaneous recovery from the block is rapid
Metabolism:
Hydrolysis by plasma cholinesterase
Dose: .15-.2 mg/kg (intubation) 4-10 mcg/kg/min infusion
Pharmacodynamics:
Onset: 1 min
Duration: 10-20 minutes

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23
Q

Benzylisoquinolines- Atracurium (Tracrium)

A

50mg 10mg/ml

Intermediate acting, Hofmann Elimination and nonspecific ester hydrolysis, small histamine release, minimal change in BP
Primary metabolite is Laudanosine, which can produce rare seizure activity (tertiary amine)
Dose: 0.3-0.6 mg/kg
Pharmacodynamics
Onset: 2-3 minutes
Duration: 20-35 min, 95% recovery in 60-70 min

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24
Q

Benzylisoquinolines - Cisatrcurium (Nimbex)

A

20mg 2mg/ml

Intermediate/long acting, predominantly Hofmann elimination, NO histamine release, NO changes in BP/HR
Dose: 0.1-.15 mg/kg IV
Onset: 2-3 min, peaks in 3-5 min
Duration: 40-70 min; 20-35 min to begin recovery: up to 93 min for 90% return

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25
Q

Reactions- drugs that cause anaphylaxis reactions

A

Under anesthesia what would you see tachycardia, hypotension, bronchospasm – wheezy peak pressure – different than an awake pt. sugammadex (high doses) , rocuronium, antibiotics

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26
Q

Factors Affecting Reversal

A

Intensity of the block
Dose and choice of NMB
Drug interactions
Choice of reversal agent
Disease process (liver failure)

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27
Q

ways to reverse a patient?

A

Time, drugs, Hoffman

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28
Q

Acetylcholinesterase Inhibitors

A

Acetylcholinesterase : enzyme responsible for rapid hydrolysis of released acetylcholine
Reversal of NMB, myasthenia gravis (Diagnosis and treatment), treatment of central anticholinergic syndrome
Inhibiting the action of acetylcholinesterase, Increase Ach
Unwanted muscarinic stimulation
SLUD- salivation, lacrimation, urination, and defecation, which are the clinical signs associated with muscarinic cholinergic overstimulation(I ADDED)
Increased bronchial secretions/bronchospasm
Bradycardia caused by slowing conduction velocity of the cardiac impulse through the AV node
CNS excitement (physostigmine)

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29
Q

Reversal Agents - Acetylcholinesterase Inhibitors/Selective Relaxant Binding Agent

A

Acetylcholinesterase Inhibitors
Neostigmine
Edrophonium
Pyridostigmine
Selective Relaxant Binding Agent
Sugammadex

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30
Q

Acetylcholinesterase inhibitors - Neostigmine (Prostigmin)

A

10mg 1mg/ml

Inhibits hydrolysis of ACh by AChAsE
Blocks AChAse at all cholinergic synapses causing parasympathetic effects
Used with glycopyrrolate (anticholinergic) to decrease muscarinic side effects of Neostigmine
Quaternary ammonium compound therefore does not penetrate the blood-brain barrier (BBB) very well
Ceiling effect- 5mg

When to Reverse with Neostigmine..

Used in deep blocks
Shouldn’t be given until spontaneous recovery evident (TOF)
More effective with moderate blocks but slow acting
Ceiling effect
Because of this ceiling effect Neostigmine can’t effectively antagonize deep blocks
Giving more may even worsen it and potentially increase the incidence of residual block
15 mins when at right time? I ad ded

Given with Glycopyrrolate- .2mg/ml 5ml vial =1 mg

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31
Q

Acetylcholinesterase inhibitor Edrophoniun (Enlon)

A

Used with atropine due to rapid onset
Inhibits the destruction of ACh by AChE
Enlon-Plus is a mixture of Edrophonium and atropine together in the same vial
Rapid onset (1-2 min), short duration
Quaternary amine
Dose:
.5-1 mg/kg mixed with atropine 0.014 mg per 1 mg of edrophonium
Enlon-plus: .05-.1 mg/kg slowly over 1 minute
Enlon plus!! Is a mixture with atropine***

Atropine is .4mg/ml 20ml vial? per pic

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32
Q

Cholinergic Syndrome (Crisis)

A

Excessive stimulation of Ach receptors: either direct stimulation of receptor or inhibition of acetylcholinesterase
Overstimulation of nicotinic and muscarinic receptors
How: Too much Anticholinesterase, organophosphate poisoning/nerve gas, certain drugs
Symptoms: Muscarinic (SLUD), muscle cramping, weakness, decrease BP/HR, CNS (restless, anxiety, confused, seizures, coma)
Treatment: Atropine, benzos (versed/valium),Oximes (pralidoxime, obidoxime)

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33
Q

Acetylcholinesterase inhibitor - Physostigmine (Antilirium)

A

Tertiary amine: only anticholinesterase (acetylcholinesterase inhibitor, cholinesterase inhibitor) that crosses the blood brain barrier
Not used for reversal of muscle relaxants
Used to treat anticholinergic toxicity
S/S: flushing, dry skin and mucous membranes, mydriasis with loss of accommodation, altered mental status, fever and urinary retention
CNS: restless, shivers, agitation, disoriented
Types of anticholinergics (atropine, scopolamine, antihistamines, antipsychotics, cyclic antidepressants)

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34
Q

Selective relaxant binding agent - Bridion (Sugammadex)

A

Used for reversal of Zemuron/Vecuronium

Selective relaxant binding agent that encapsulates rocuronium or vecuronium preventing its action: can reverse profound neuromuscular blockade
What’s the dose of Sugammadex?

Dosing for Rocuronium and Vecuronium
2 mg/kg TOF of 2
4 mg/kg 1-2 post-tetanic counts (PTC) and no TOF twitches
Dosing for Rocuronium only
16 mg/kg to reverse RSI dose of Rocuronium of 1.2 mg/kg after 3 minutes

What are the Warnings and Precautions on Sugammadex?

Anaphylaxis and Hypersensitivity
Bradycardia
Risk of coagulopathy and bleeding
Increases in PTT and PT, especially in those who were treated with heparin or low molecular weight heparin for thromboprophylaxis
Interactions with other drugs (hormonal contraceptives and Toremifene)……… suggest NO sex for 7 days
Common adverse reactions: N/V, hypotension, headache

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35
Q

Anticholinergic Agents/Muscarinic Antagonists

  • Muscarinic Antagonists
A

Competitive inhibitors of Ach at parasympathetic muscarinic receptors to increase the heart rate
Inhibits salivary, bronchial, and GI secretions
Reduces gastric motility
Causes bronchodilation
Antagonize the muscarinic effects of anticholinesterases used to reverse NDMR

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36
Q

Atropine

A

Competitive acetylcholine antagonist at central and peripheral receptors, antimuscarinic, naturally occurring alkaloid
Tertiary amine
Indications: reversal, brady arrhythmias/vagal stimulation, oculocardia reflex, peritoneal stimulation
Careful use in narrow-angle glaucoma
Crosses placenta to increase FHR and decrease beat to beat variability in baby
Dose: 0.014mg / mg of edrophonium or .2-.4mg for vagal stimulation
Onset: <1 min; duration: up to 30 min
Dilating an eye with narrow angle glaucoma closes the angle completely. Medications can worsen both types of glaucoma.

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37
Q

Glycopyrrolate (Robinul)

A

1mg .2mg/ml

Synthetic antimuscarinic, competitive Ach antagonist
Uses: in combo with Neostigmine for reversal, antisialogogue(xerostomia), increase HR
Quaternary ammonium
Dose: 0.2 mg per 1 mg Neostigmine
Onset: about 1 min IV; 15-30 min IM
Duration: 2-4 hours
No CNS or mydriasis

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38
Q

Scopolamine

A

.4mg/ml

Competitive antagonist of Ach at muscarinic receptors, antagonizes histamine and serotonin
Tertiary amine, naturally occurring alkaloid
Uses: Decreases secretions, PONV, motion sickness/vertigo, dilate pupils and cycloplegia, unstable trauma pt, sedation/amnesia
Toxic psychosis in elderly
Effects from restlessness to agitation
IM/IV before surgery; transdermal patch (what should we warn them about)
Typical dose: 0.3-.5 mg IM or IV

Cycloplegia: paralyzing the ciliary muscle and thus the power of accommodation.

Crosses BBB – more geared toward motion sickness- different drug with different modes of action for PONV – careful with older pts

dilate eyes… Also dry mouth***

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39
Q

Central Anticholinergic Syndrome

A

Overdose of scopolamine and sometimes Atropine(tertiary amines), phenothiazine
Signs: anxiety, disoriented, hyperactive, sedation, seizure, mydriasis, increased HR, Atropine flush, dry/flushed skin, atropine fever
Can be mistaken for delayed recovery from anesthesia
Treat with Physostigmine: tertiary amine that crosses the BBB
Dose: 1-2 mg IV and may need to be repeated every 1-2 hours (physostigmine is metabolized rapidly)

Muscarinic Antagonist Toxicity
Anticholineric toxidrome - pic

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40
Q
  • *Vasopressors/**
  • *Sympathomimetics- Vasopressors are not a replacement for:**
A

Adequate volume
Blood
TOO MUCH ANESTHESIA

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41
Q

Ephedrine

A

Mixed acting synthetic noncatecholamine sympathomimetic
Indirect Effect
Ephedrine into Alpha-1 and Beta-1 receptors displaces norepinephrine presynaptic
Norepi is released and activates the postsynaptic receptors to cause arterial and venous vasoconstriction and increased myocardial contraction
Direct Effect
Directly stimulates Beta-2
Increased heart rate, cardiac output and some SVR increase

Uses: increase BP/HR, CO and contractility, PONV, bronchodilator effect
Used in Obstetrics: can cause fetal tachycardia and acidosis which was associated with lower umbilical artery pH at delivery
Contraindicated with MAO inhibitors, Pheochromocytoma
Careful use in CAD
Tachyphylaxis (depletion of presynaptic norepi)
Dose: 5-10 mg at a time to increase BP/HR; Ephedrine 25mg/Vistaril 25 mg IM for antiemetic effect 20 min before end of surgery
50mg 5mg/ml - make by taking 1ml with 9ml of normal saline = 1cc (50 mg) + 9 cc of NS = 5 mg/cc

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42
Q

Phenylephrine (Neosynephrine)

A

Directly stimulates alpha-1 receptors, minimal effect on alpha-2 or Beta receptors
Uses: hypotension, decrease CO in patients with LV dysfunction
Causes constriction of cutaneous, mesenteric, splenic and renal
Vasopressor of choice in OB
Causes vasoconstriction to increase BP, reflex decrease in HR, increase in coronary blood flow
Dose: 50-100 mcg titration to effect
100 mcg/ml 1g in 10ml how to mix = .1 cc (10mg/cc vial) + 9.9 cc NS = 100 mcg/cc

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43
Q

EPHEDRINE vs. NEO in OB

A

Ephedrine won’t decrease uterine blood flow
Some antiemetic property, good for hypotension from regional anesthesia
Can cause fetal tachycardia and acidosis

Neosynephrine is preferred in OB now
Good for hypotension post-regional
Faster onset and shorter duration of action
Maintains fetal pH

44
Q

WHY IS THE PATIENT HYPERTENSIVE?

A

Identify the potentially reversible causes of hypertension!
Pain
Hypothermia
Anxiety
Increased ICP
Bladder distention
Poorly controlled HTN
Lack of anesthesia

45
Q

Labetalol (Trandate)

A

Nonselective Beta-1 and Beta-2 with selective Alpha-1 adrenergic antagonist, primarily considered a Beta Blocker
Uses: acute and chronic HTN in pregnant pts, treat increases in BP and HR from stimulation (intubation)
BP reduction causes decreased CO and PVR, can depress cardiac contractility, minimally affects CBP or ICP
Contraindicated in bronchospastic disease, impaired cardiac conduction or underlying resting bradycardia
Dose: 5-20 mg boluses IV; onset: 1-2 min; duration: up to 6 hours
100mg/20ml 5mg/ml

46
Q

Esmolol (Brevibloc)

A

Rapid-onset and short-acting selective Beta-1 antagonist
Uses: treat perioperative tachycardia, pre-treatment during intubation/extubation
Decrease in HR, myocardial contractility, CO and some decrease in BP, no rebound effects
Contraindicated in bradycardia, heart block, cardiogenic shock and heart failure
Dose: 10mg boluses IV, infusions of 50 mcq/kg/min after a .5mg/kg bolus; Onset: rapid; duration: 10-15min
Metabolized by plasma esterases
100mg 10mg/ml - fast on fast off

47
Q

Propranolol (Inderal)

A

Nonselective Beta-1 and Beta-2 antagonist
Uses: HTN, angina, acute MI, pheochromocytoma, treat anxiety and panic attacks
Decreases BP due to decrease in myocardial contractility, HR, CO therefore decrease in myocardial oxygen demand
Careful use in bronchospastic disease, AV block and bradycardia
Dose: 1 mg-3mg IV (no more than 1 mg/min), titrated to effect; onset: around 2-3 min; duration up to 4-6 hours (depending on the source you read)
may give Esmolol not working 1mg/ml

48
Q

Metoprolol (Lopressor)

A

Selective B1 adrenergic receptor antagonist, prevents inotropic and chronotropic responses to Beta stimulation
Uses: rapid HR and contractility control, CO and therefore decrease BP, treatment for MI
Dose: 1-5 mg IV up to 15 mg
Half-life of 3-4 hours
5mg 1mg/ml

49
Q

Vasopressin

A

Antidiuretic hormone, released by the posterior pituitary
V1 (CV effects), V2 (renal), V3 (pituitary) receptors
Uses: cardiac arrest, sepsis, shock and hypotension secondary to ACE inhibitors refractory to catecholamines or sympathomimetics
Dose: I0/20 units/ml in 10/20 ml syringe, 1-2 unit bolus (mix with Saline)
Potent vasoconstrictor: arterial and mesenteric
I think used in vasoplegia

1unit per ml?

50
Q

Hydralazine (Apresoline)

A

Direct systemic arterial vasodilator causing relaxation of arterial smooth muscle; blocks calcium release from sarcoplasmic reticulum; decreases BP with increase in HR, SV, and cardiac output
Uses: HTN, heart failure, Eclampsia
Potential for increased ICP, careful/contraindicated in CAD
Dose: 2.5-5 mg IV titrated every 20-30 min; onset: 15-30 min; duration: 4-6 hours
20mg/ml

pregnant start labetalol then hydralazine then nitroprusside

51
Q

What is PONV

A

Postoperative nausea and vomiting (PONV) defined as nausea and/or vomiting within 24 hours of surgery

Along with pain, PONV is the highest complaint and leading cause of unanticipated hospital admission after outpatient surgery

40% of patients without prophylaxis have nausea who have general anesthesia
80% of high risk patients without prophylaxis

52
Q

Risk Factors for PONV

A

Patient factors: female(strongest indicator), nonsmoker, hx of PONV and/or motion sickness
Surgical factors: longer procedures, certain procedures (GYN, laparoscopy, ENT, Breast/Plastics)
Anesthetic factors: inhalationals, nitrous?, neostigmine, opioids

Kids: weak association with age, greatest association is the surgical procedure (hernia, tonsils/adenoids/ strabismus surgery, male genitalia)
Adults: risk may decrease with age

53
Q

PONV MULTIMODAL

A

PONV is associated with: dehydration, electrolyte abnormalities, wound dehiscence, bleeding, airway compromise and UNPLANNED ADMISSIONS and PATIENT DISCOMFORT

54
Q

Scopolamine

A

Prevention of Motion Induced nausea and PONV
Trauma patients
Motion sickness is caused by stimulation of the Vestibular apparatus
Opioids and morphine increase vestibular sensitivity to motion!
Transdermal absorption of scopolamine (sustained plasma concentration) so may have less sedation, cycloplegia and drying of secretions
Visual disturbances due to anisocoria (unequal pupil size)

55
Q

Zofran (Ondansetron)

A

Selective 5-HT3 receptor antagonist in GI tract and Chemoreceptor Trigger Zone
Preventative and rescue treatment for N/V, used in chemo
Side Effects: headaches, diarrhea
Careful use in patients with prolonged QT interval: can lead to torsades
Questionable use in Obstetrics
Dose: 4 mg IV; duration: 4-6 hours; extensive hepatic metabolism WHEN DO YOU GIVE IT? literature 10 mins before end 4 hrs maybe 2x?

4mg 2mg/ml

56
Q

Decadron (Dexamethasone)

A

Nausea and Vomiting prevention, ENT, traumatic intubations…..
Corticosteroid, used in combination with other antiemetics, lowers surgical inflammation, low cost
Mechanism is unclear, proposed to centrally inhibit prostaglandin synthesis and control endorphin release
Side effects: genital itching/burning (give after patient asleep), hyperglycemia
Careful in diabetics, wound healing issues?
Dose: 4-12 mg IV on induction; duration about 24 hours
20mg 4mg/ml

57
Q

Phenergan (Promethazine)

A

Phenothiazine, H1 receptor antagonist (antihistamine), Anticholinergic action (motion sickness), D2 antagonist in CTZ
Considered a First-generation H1 receptor antagonist due to sedation potential
Uses: N/V and anxiety
Causes sedation, potentiates sedative effects of benzos and opioids (Cesarean delivery), hypotension, extrapyramidal symptoms (Akathisia)
Dose: 12.5-25 mg IV (diluted and given slowly in good IV); onset: 3-5 min; duration: 4-6 hours
50/25mg /ml?

dont give to parkinson patient?

58
Q

Aspiration Prophylaxis

A

Factors associated with pulmonary complications of aspiration:

Volume of gastric contents
Acidity of the aspirated gastric contents

59
Q

REGLAN (METOCLOPRAMIDE)

A

Gastrointestinal prokinetic, increases LES tone, enhances response to AcH in upper GI tract to enhance gastric motility and accelerate gastric emptying/reducing gastric volume
Antiemetic action probably due antagonism dopamine-agonist effects in the chemoreceptor trigger zone
Inhibition of dopamine receptors within the CNS….. Crosses the BBB
Can cause sedation, restlessness, extrapyramidal symptoms (tardive dyskinesia)
Contraindicated bowel obstructions and Parkinson’s, restless leg syndrome, or movement disorders related to dopamine inhibition or depletion
What pt would you not give this to- small bowel obstruction… Parkinson, old people**= they can have increase Parkinson make crazy kinda like scpalmine

Treatment of diabetic gastroparesis, GERD, OB
Usually given in preop for aspiration prophylaxis
Does not alter gastric fluid pH
Dose: 5-10 mg IV in preop; duration: 1-2 hours; onset: 1-3 minutes, can be used as a rescue drug in PACU
Potential for Neuroleptic Malignant Syndrome
What is NMS?
How is it treated?
What other syndrome is it similar to?
10mg 5mg/ml

RSI, Trauma, pego, bad reflux – aspiration prophylaxis only moves things but does not help with gastric ph

60
Q

Pepcid (Famotidine)

A

H2- receptor antagonist, inhibits gastric acid secretion/fluid volume and raises gastric pH
Given in preop to decrease risk of pulmonary aspiration in at risk patients
Dose: 20 mg IV
Onset: 30 min – 1 hour

20mg 10mg/ml

61
Q

Vistaril (Hydroxyzine)

A

Blocks Ach in the vestibular apparatus, blocks H1 receptors in the solitary tract, antihistamine
Uses: N/V, pruritus (pregnancy), antianxiety
Side effects: sedation, pain on injection
Dose: 25 mg mixed with Ephedrine 25 mg IM 20 minutes before the end of surgery (careful in HTN patients/outpatients)

100mg 50mg/ml

62
Q

OB- Pitocin (Oxytocin)

A

Uses: induction of labor and control postpartum uterine bleeding, after Suction D&C
Indirectly increases intracellular calcium, directly stimulates the oxytocin receptor on the myometrium, some antidiuretic
Contraindicated in: fetal distress, unfavorable fetal positions, previous uterine rupture
Effects: flushing, brady/tachycardia, hyper/Hypotension
Dose: 10-40 U in 1000cc LR; onset: immediate; duration: within 1 hour

PRESSOR EFFECTS? We never give IV*

63
Q

OB- Methergine (Methlyergonovine)

A

Semisynthetic ergot alkaloid, increases motor activity of uterus by acting directly on smooth muscle to increase tone, rate and amplitude of contraction
Arterial vasoconstriction by alpha stimulation, inhibition of endothelial derived relaxation factor release
Contraindications: severe HTN, PIH and cardiac disease
Dose: 0.2 mg IM every 2-4 hours (max 5 doses); onset: 2-5 min; duration: about 3 hours
NEVER IV can raise BP alpha. .2mg/ml

64
Q

OB- Hemabate (Carboprost)

A

Synthetic analogue of prostaglandin F2 that stimulates uterine contraction, increase of myometrial calcium, stimulates smooth muscle of GI tract to cause diarrhea
Increase in temperature possibly due to effect on hypothalamic thermoregulation(can increase 2 degrees)
Airway constriction and wheezing, increase CO, BP and PVR (constriction of vascular smooth muscle)
Dose: 250 mcq IM repeated every 15-45 min, max 8 doses; onset: immediate; duration: 2 hours
250mcg/ml

65
Q

OB- Misoprostol (Cytotec)

A

Synthetic prostaglandin E1
Indicated for uterine atony, abortions, cervical ripening, peptic ulcer disease
Dose: 1-2 tablets buccal (200 mcq each), can be given rectally and vaginally (By OB); onset: rapid; half life is 20-40 min

66
Q

Magnesium Sulfate (MgSO4)

A

Used to prevent eclamptic seizures (decrease incidence of seizure by 50 %), stop premature labor (tocolytic)
Inhibition of acetylcholine release at NMJ
Mild vasodilator that decreases uterine activity to increase uterine blood, dilates liver beds and kidneys to increase function, decrease SVR
Potentiates nondepolarizers and depolarizers (probably not enough to alter dose)

Can cause pulmonary edema, may be some correlation with chorioamnionitis
Dose: 4 grams over 20 min, 2-3 grams/ hour infusion; onset: immediate; duration: 20-30 min with good renal perfusion
Monitor magnesium levels, treat magnesium toxicity with calcium gluconate 1 gram over 2 min, fluids, diuresis, O2
Crosses the placenta therefore neonate may show signs of respiratory depression, apnea and decreased tone

Mg plasma levels- pic

67
Q

Blood Pressure Control In Parturients

A

Labetalol: combined alpha and beta antagonist, rapid onset, few neonatal complications (bradycardia)
Hydralazine: potent vasodilator, decrease afterload, decrease peripheral resistance (especially when used with volume repletion), decrease maternal BP and uterine vascular resistance to increase Uterine blood flow
Limiting side effects are maternal tachycardia (reflex sympathetic response to direct vasodilation), vomiting, tremors

Nipride: for acute hypertensive crisis, potent arteriolar dilator, rapid onset and short duration, maternal/fetal cyanide toxicity is a concern, but at low doses 5-10 mcg/kg/min is unlikely
Nitro: venodilator to decrease cardiac filling pressures by acting on capacitance vessels, may get reflex tachycardia
Volume Repletion for severe pre-eclampsia, intravascular repletion can improve the low CO, when right and left cardiac filling pressures normalize, CI improves, maternal HR and SVR decrease, fetal circulation improves

68
Q

Gabapentin (Neurontin)

A

Gabapentinoid
Decrease hyperexcitability of dorsal horn neurons caused by tissue damage
Modulation of calcium-induced release of glutamate centrally in dorsal horn
Activation of descending noradrenergic pathways in the spinal cord and brain
300-600 mg PO preop
Careful in old age and low GFR, morbidly obese, OSA
Used a lot in chronic pain/neuropathic pain
Can increase postoperative sedation

69
Q

Celebrex

A

Selective COX-2 inhibitor
PO dose of 100-200 mg
Associated with increased risk of stroke and MI, worsening of HTN
Careful/Avoid in known history of CAD or cerebrovascular disease

-I added - COX-1 generates prostaglandins that are involved in the protection of gastrointestinal mucosa, while COX-2 generates prostaglandins that mediate inflammation and pain in sites throughout the body.

70
Q

Methocarbamol (Robaxin)

A

Central Acting Skeletal Muscle Relaxant
Depresses the CNS leading to relaxation of the muscles
Used as an adjunct with other medications
Can cause sedation
Dose: 1 gram IV slowly over 15-20 minutes
Can cause hypotension, bradycardia, and convulsions if given rapidly
Should probably be avoided in liver and renal dysfunction

also get chills?

71
Q

Toradol (Ketorolac)

A

NSAID, inhibits cyclooxygenase, preventing thromboxane synthesis, which is necessary for platelet aggregation, inhibits prostaglandin synthesis
Non-Selective Cox 1 and Cox 2 inhibitor
Uses: decrease pain and cramping, postoperative cesarean delivery, orthopedics, laparoscopy….
Minimal CNS effects, no respiratory depression or sedation
Careful in elderly and renal

Careful use in elderly, bleeding issues, renal impairment with poor creatinine clearance, ASA allergy, asthma, nasal polyps
Decreases narcotic us postop
30 mg Toradol IV = about 10 mg morphine
Dose: 15 – 30 mg IV every 6 hours; Onset: 10-30 min; Duration: 4-6 hours; peaks in 1-2 hours

Take Home: We use Toradol frequently. Make sure your patient has no relative or absolute contraindication to its use.
Always ask the surgeon before administering

72
Q

Samter’s Triad

A

-added syndrome of airway inflammation characterized by rhinosinusitis with polyposis, asthma, and nonsteroidal anti-inflammatory drug (NSAID) intolerance. Samter’s Triad is usually treated by managing asthma symptoms, taking corticosteroids, and having nasal surgery to remove polyps

Also called Aspirin Exacerbated Respiratory Disease (AERD)
Chronic condition that includes all three triad features and sensitivity to NSAIDS and ASA
Acute reactions to aspirin and NSAIDs can be severe and life threatening
Usually diagnosed in adulthood (7-10% of adult)
May have respiratory reactions to alcohol and impaired sense of smell

73
Q

Ofirmev (IV Acetaminophen)

A

Non-opioid alternative or in combination with other drugs
Careful use in hepatic impairment/Acute disease, chronic alcoholism, chronic malnutrition, severe hypovolemia, or severe renal impairment
Dose: >50 Kg dose is 1000 mg IV over 15 min, repeated every 6 hours or 650 mg every 4 hours (Max 4 grams in 24 hour period); < 50 Kg adult is 15mg/kg every 6 hours not to exceed 3g/day
PO in preop

74
Q

Caldelor 800mg/8ml

A

CALDOLOR must be diluted prior to use. Infusion of the drug product without dilution can cause hemolysis. CALDOLOR should not be given as an IV bolus or IM injection.
ADVERSE REACTIONS:The most common adverse reactions are nausea, flatulence, vomiting, headache, hemorrhage and dizziness (>5%). The most common adverse reactions in pediatric patients are infusion site pain, vomiting, nausea, anemia and headache (≥2%).
Max dose: 3200 mg/day (800 mg/6 hours) or 2400 mg (40mg/kg) in Pediatrics less than 17 years old

CONTRAINDICATIONSCALDOLOR is contraindicated in patients with known hypersensitivity (e.g., anaphylactic reactions and serious skin reactions) to ibuprofen or any components of the drug product, and in patients who have a history of asthma, urticaria, or other allergic-type reactions after taking aspirin or other NSAIDs.
WARNINGS AND PRECAUTIONSCALDOLOR should be used with caution in patients with known cardiovascular (CV) disease or risk factors for CV disease, a history of peptic ulcer disease and/or GI bleeding, liver disease or symptoms of, hypertension, and heart failure.
Avoid use in pregnant women starting at 30 weeks gestation.

75
Q

Methylene Blue

A

Potent Monoamine oxidase inhibitor (MAOI)
Interacts with Serotonin reuptake inhibitors (selective and nonselective, SSI/SSRI) and SNRI (serotonin-Norepinephrine)serotonin toxicity
Can induce severe, potentially fatal serotonin toxicity (serotonin syndrome)
Careful with BLUE ARM syndrome (no cuff)

Serotonin Toxicity- pic

76
Q

Fluorescein Dye

A

Used to Visualize ureters during cystoscopy
Intraoperative urologic dye marker
Dose: dependent upon practitioners
50-100 mg IV (100 mg/ml)
Usually works within 5 minutes
Precautions:
Bronchial asthma
Avoid extravasation

77
Q

Indigo Carmine

A

Inactive blue dye routinely given IV during urologic and gynecologic procedures to localize the ureteral orifices
Dose: 5 ml (8mg/cc)
Can see hypertension due to increased PVR with increased HR
Can see Increased BP with reflex decrease in HR
On rare occasion can see Hypotension, cardiac arrest and cerebral ischemia

78
Q

Other Drugs/Infusions You Should Review

A

Nitroglycerine
Nipride
Dobutamine
Dopamine
Review your opioids (Dilaudid, Fentanyl)
Cox-1 and Cox-2 inhibitors (Celebrex)
Gabapentin

79
Q

Nonspecific plasma esterase

A

Remifentanil
Esmolol
Remimazolam
Clevidipine
Atracurium (and hofman
Etomidate (and hepatic)
Cisatracurium- 30% hof and rest nonspecific?

80
Q

AIP ( ACUTE intermittent porphyria

A

Etomidate and Barbituates, oral contraceptives, and sulfa drugs
5 ps – Porphobilinogen deaminase deficiency; Pain in abdomen; Psychological symptoms; Peripheral neuropathy; Pee abnormality; Precipitated by drugs
- Disorder of porphrin enzyme metabolism in liver or bone marrow- they are involved in heme production. If history must avoid barbs and etomidate. Thiopental and methohexital

81
Q

Protein bound

A

98% propofol
98-94% benzodiazepine-
94%- Dexmedetomidine
75% Etomidate
20% Ketamine- high lipid solubility

82
Q

GABA A

A

Propofol (receptor agonist) (enhancement of GABA inhibition – maybe central cholinergic transmition NMDA, alpha adrenergic sites)
Etomidate (agonist)
Benzodiazepines- agonist -central inhibitory neurotransmitter ( increase frequency of opening * increase chloride conductance- hyperpolarization of membrane incr resistance to stim. )
Barbiturates- gaba a agonist – involves cortical and brainstem GABA inhibitory pathway

83
Q

NMDA (N- methyl – D – aspartate)

A

Ketamine - antagonist (phencyclidine PCP derivative) (racemic mixture of S and R enantiomers).. also non-NMDA glutamate receptors, Nicotinic receptors, cholinergic recpetors, monoaminergic receptors, Mu, delta, and kappa – opioid receptors, and inhibits neuronal Na+ channels (local anesthetic action) and Ca+ channels (cerebral vasodilation)

84
Q

Alpha 2 adrenergic agonist

A

Dexmedetomidine- highly selective specific potent a2 adrenergic agonist compared to clonidine 7-8x more selective- dose dependent sedation/analgesia

85
Q

Glycerol

A

Propofol
Etomidate (propylene glycol) – veno-irritation/ phlebitis
Versed does not burn its water soluble but… Lorazepam and diazepam do vein irritant* propylene glycol
Pain on injection - Methohexital

86
Q

CNS

A

Propofol (depressant, neuroprotective anticonvulsant (treat status epilepticus), decrease CMRO2, CBF, and ICP… shortens sz duations (ECT), decrease PONV (10-15 mg IV or 10 micogram/kg/min.) antipruritic effect (10mg)

Etomidate- potent vasoconstrictor – reduces CBF, ICP, CMRO2 (myoclonic movements- sz like – use versed/opioid to help; PROconvulsant; lowers sz threshold

Ketamine- POTENT cerebral vasodilator – increases CBF 60-80%) in normocapnia attenulated with hyperventilation maybe not use increased ICP?? dissociative amnestic state- unconscious – eyes open (nystagmus), maintain spon resp. does not react to pain, prevents hyperalgesia and decrease sensitization to acute pain, acute pain and depression treatment

Dexmedetomidine – sedative, anxiolytic, analgesic (spinal cord and brain) pt can follow commands

Benzodiazepine- ANTICONVULSANT , skeletal muscle relaxant (centrally), anxiolysis and sedation, amnesia – Decreaces CMRO, CBF, little effect ICP, upper aireway reflex may decrease and central resp drive.

Barbiturates – CNS depressant, neuroprotective, anticonvulsant, decreases CMRO2, CBF, ICP (EEG burst suppression thiopental)- loss of consciousness, hypnotic effect- inhibit central excitatory pathway- glutamate via NMDA receptors and acetylcholine Thiopental- anticonvulsant treat status epilepticus – used induction pt with increased ICP and treats ICP resistant to hyperventilation- Protects the brain- decreases CBF ICP, CRMO2 – releases histamine from mast cells- Precipitates with succinylcholine, rocuronium and lidocaine Methohexial (brevital) – gold standard for ECT- half-life elimination 4 hours, *proconvulsant* activity pain on injection

87
Q

CV

A

Propofol- decrease SVR, Stroke volume, and CO systolic and diastolic, decrease sympathetic activity- vaso and venodilation – more so after larger dose (dependent),
Etomidate- hemodynamically stable** (cardio, trauma, hypovolemic) no effect on it…
Ketamine – SNS stimulant induction dose increases HR and BP MAP CO SVR(good for unstable) OB, careful- cardiac severe right heart dysfunction (increases PVR) (good for hypovolemic but not critically ill/shock** they might drop bp if depleted catecholamine stores.
Dexmedetomidine – hypotension and bradycardia because high alpha 2 adrenerreceptor activity- esp children – titrate.. blunt hemodynamic SNS effects laryngoscopy – stability as adjuvant
Benzodiazepine- minimal cardio depression, can decrease SVP and BP
Barbituates- decreases mean arterial pressure, venous vascular tone, and CO, CV depression

88
Q

Pulmonary

A

Propofol - Resp depress, potent bronchodilator (intracellular ca+), apnea common, maintence dose- increase RR decrease TV
Ketamine- no significant depression of vent. Protects airway reflex, muscarinic receptors can increase secretions( glyco) Broncodilates good**
Dexmedetomidine- minimal respiratory depression- bolus reduces minute ventilation
Benzodiazepines- minimal resp depression ( reversible with flumazenil)
Barbiturates- dose dependent respiratory depression- does not cause bronchodilation

89
Q

Major side-effects

A

Propofol- pain with injection and propofol infusion syndrome, phenyl nuclus and di-isopropyl sidechain – allergic reactions, also genergic metabisulfite* sulfite sensitivity. Egg/soy- egg white, carful- CV disease trauma/hypotension/ bleeding PROPOFOL infustion syndrome (PRIS) high doses 4mg/kg/hr over 48 hours – acute refractory brady – asystole, unexplained meta acidocis, high K+, rhabdomyo, hyperlipid, enlarged liver, renal failure, EKG and arrhythmida, cardiomyopathies, skeletal mypo high k+ - critically ill (or peds)….
Etomidate – adrenocortical suppression – inhibit 11-beta-hydroxylase prevents cholesterol to cortisol, PONV,
Ketamine- Emergence delirium, 5-30%, greater than 2mg/kg, prevent- midazolam, pharm test included bleeding?
Dexmedetomidine- bradycardia (40%) and hypotension can give atropine, ephedrine or volume, also omitting loading dose. Can causse dry mouth/nausea and HTN..
Benzodiazepine – can have anterograde amnesia (OB)

90
Q

Metabolism

A

Propofol- liver – inactive and water -soluble metabolytes kidneys excreted- extrahepatic sites of metabolism 30% kidneys and lungs – broken down pts with different comorbid states..
Ketamine- liver – cytochrome P – 450 enzyme- ACTIVE metabolite Noreketamine- (1/3-1/5 as active)
Etomidate- PLASMA ESTERASES and liver – excreted kidneys 80% and bile 20%
Dexmedetomidine- Rapid hepatic metabolism involving conjugation, n-methylation, hydroxylation- excreted urine and feces- distib 1/2l 6min elim 1/2l 2 hrs… weak inhibitory properties on CYP-450 can increase plasma concentration of opioids
Benzodiazepine
Versed- rapid redistribution, hepatic metabolism and renal clearance (careful renal liver dysfuction, age, comorbidies) – 1- hydroxymidazolam metabolite high hepatic clearance
Diazepam- intermediate duration- metabolites- oxazepam and desmethylidaepam – slow
Lorazepam (long acting inactive metabolietes
Barbiturates- primary metabolism is hepatic with inactive metabolites excreted in urine and bile

91
Q

Propofol (2,6 -diisopropylphenol)

A

1-2.5 mg/kg
30 sec – unconscious
Iv MAC- 25-75 mcg/kg/min
TIVA GA – 100-200 mcg/kg/min
Concentration 10mg/ml (200mg/20ml)
Context sensitive half-life – 8 hours - 40 mins

92
Q

Etomidate (carboxylated imidazole derivative)

A

Initial distribution half-life: 2.7 minutes
Redistribution of half-life: 29 minutes
Elimination half-life: 3-6 hours
Volume of distribution: 2.5-4.5 L/kg
Induction dose: 0.2-0.3 mg/kg
Usual concentration: 2mg/cc (20mg/10ml)

93
Q

Ketamine

A

Onset of IV meds: 30-60 seconds
Duration: 10-20 minutes
Induction dose: 0.5-2 mg/kg IV
4-5 mg/kg IM
◦
Usual concentrations: 10mg/cc (200mg/20ml)

94
Q

Dexmedetomidine

A

Dose .5-1 mcg/kg over 10 mins (don’t want brady)
Infusion .2-.7 mcg/kg/hr
Syringe- 4 mcg/ml (80mcg/20ml)

95
Q

Benzodiazepines-

A

have many routes- versed (shortest acting) PO IV IM Rectal, intranasally, (50% first pass hepatic ( reversal of benzos- FLUMANZENIL (romazicon) .2 mg iv over 15 seconds redoes 45 seconds if no response… every 1 min can give 4 doses max- does not last as long as the benzo sometimes.

Most common- midazolam (versed) children often oral .5mg /kg 30 min before OR.. adult 1-2 mg in preop iv. Its additive. – mild if any vein irritiation
Onset of IV meds: 30-60 seconds
Duration: 10-20 minutes
Induction dose: 0.5-2 mg/kg IV
4-5 mg/kg IM

Usual concentrations: 10mg/cc

96
Q

Barbiturate class

A

Oxybarbituates ( primidine center – O2 atom on #2 carbon)- Methohexital
Thiobarbiturates (pyrimidine center) replace the O2 with sulfur on #2 carbon – Thiopental
Thiopental- long elimination half-life 12 hours
Methohexital
◦ Induction dose
◦ 1-2 mg/kg (IV)
◦ 20-30 mg/kg (Rectal)
Thiopental
◦ Induction dose
◦ 2.5-5 mg/kg (IV)
◦ In the elderly reduce the dose by 30-35%

97
Q

Paralytics

A

CV
Succinylcholine – sinus brady, junctional, arrest – more common 2nd dose- children- atropine… action at cardiac muscarinic cholinergic receptors
Rocuronium (zemuron)- no effect on BP/ HR
Vecuronium (norcruon) – cardiac stable
Pancuronium- Vagolytic effects- modest tachycardia – antimuscarinic stimulation- direct sympathomimetic effect- noreepi reduced uptake by adrenergic nerves. Increase HR and CO—sometimes cardiac surgery – high dose opioid counteracted
Cisatracurium- no changes
CNS
SCh - Increased intracranial pressure?
Muscular
Succinylcholine- Fasciculations- 80-90% if not pretreated with nondepolarizer or NSAID – Myalgias – 50-60%

98
Q

Side effects

A

SCh- malignant hyperthermia/muscular dystrophy- myoglobinuria … raise K+ .5-1 in healthy people… worse in burns, severe abd infection, metabolic acidosis, upreg extrajunctional ACHR (hemiplegia, paraplegia, muscular dystrophies, guillian-barre syndrome, and burns… Risk in children don’t know if undiagnosed muscle- hyper kalemia , rhabdo. Only emergency increased gastric pressure? Lower esophagial tone? Increased introcular pressure? I
Vecuronium (norcuron)- might precipitate with thiopental

99
Q

Histamine paralytics

A

Mivacurium (Mivacron) – profound histamine release- give slow
Atracurium (tracrium)- some release- flush tachycardia hypotension
Rocuronium – rare
Vecuronium – no histamine
Pancuronium (Pavulon)- no histamine
Cisatracurium- no release

100
Q

Metabolites paralytics

A

Vecuronium- not bad one but – 3-desacetyl – 60% potent
Pancuronium- need to know 3-OH pancuronium- it is 50% potency and worried about the vagolytic effect get tachycardia
Atracurium (tracrium) Laudanosine- rare seizure activity- tertiary amine – CNS stimulant
Benzylisoquinolines – hofmann elimination – no organ or enzyme needed temp and ph dependent increase increase metabolism.
Mivacurium- hydrolysis by plasma cholinesterase
Atracurium metabolism- same enzymes for esmolol and remifentanil – hofmann elminiation 30% and ester hydrolysis for 60%
Cisatracurium – 30% hofmann metabolite breakdon by nonspecific esterase

101
Q

Sch

A

SCh- 1-1.5 mg/kg 20mg/ml succinylcholine

102
Q

Rocuronium

A

Rocuronium .6 mg/kg RSI 1.2 mg/kg
Maintence repeat .1 mg/kg
Defasciculating – 5mg or 10mg?
Onset 1-2 mins … duration about 30 min RSI 70 min
70% liver 30% renal
10mg/ml?

103
Q

Vecuronium

A
  • Induction .1 mg/kg
  • 10mg vial- reconstituted with 9ml ns.
  • Maintain .01 mg/kg
  • Onset- 2-3 mins 3-5 max
  • Duration- 25-40 for 25% 45-60 mins 95%
  • 1mg per ml must dilute first
104
Q

Benylisoquinolines
Mivacurium

A

Benylisoquinolines
Mivacurium
.2 mg/kg and 5-8 mcg/kg/min onset- 1 min duration 10-20 mins

105
Q

Benylisoquinolines
Atracurium, cisatracurium

A

Atracurium
.5 mg/kg onset 2-3mins duration - 20-35 mins – 95% recovery 60-70 mins
Cisatracurium
.15-.2 – mg/kg onset- 2-3 mins peak 4-7 duration- 40-70 – 20-25 begins and 90% 93 mins
2mg per ml

106
Q

Reversal

A

Neostigmine- .04-.08 mg/kg – every 1mg/ml od neostigmine mix with .2mg glycol (1ml)
Onset- 15 mins – duration 1-2 hrs- hepatic metabolism excretion urine
Edrophonium-(more rapid) .5-1mg with 7-10 mcg/kg of atropine enlon .05-.1mg / kg slowly over a min
Sugammadex- is different encapsulates modifiec y-cyclodextrin- 8 sugars water soluble binds rocuronium then vecurnoum. T2- 2mg/kg 2 mins, PTC 1-2 – 4mg/kg 3 mins.., 16 mg – given right after dosing 1.5mins recovery- can have negative effects high dose- brady hypo headache arrest itchy – need contraceptieves 7 days ** incompatible with verapamil, ondansetron and ranitidine -anaflaxsis- give epinephrine- 10-20 mcg , Benadryl, dexamethasone, and famotidine
Physostigmine- only anticholinesterase that crosses BBB- treats anticholinergic toxicity
Cholinergic crisis- atropine 35-70 mcg/kg
Pralidoxime 15 mcg/kg every 20 mins
Benzos

Neostigmine and edrophonium are/have:
poorly lipid soluble
large volumes of distribution

test 2 GP (4 decks)

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