Top Drawer- S3 Flashcards
Stimulation of GABAa receptors, high lipid solubility.
Uses: TIVA, induction, antiemetic, endoscopy, MAC.
Pain on injection-give w lidocaine
CV: decreased HR and BP, decreased SVR.
Decrease in CBF and ICP.
Propofol
Propofol can support bacteria how long is it good for open.
1. In opened vial infusion?
2. Drawn up in syringe?
12 hours infusion
6 hours syringe
Contraindications to Propofol?
Egg or soy allergies?
Patients with low CO or hypovolemia.
Will decrease HR and BP even more
Propofol dosing?
INDUCTION
MAC/MAINTENANCE
Propofol onset
Propofol Duration
Induction=2mg/kg
MAC=25-200mcg/kg/min
Onset= 30secs rapid
Duration= Dose dependent
Propofol metabolism?
In the liver to 4-hydroxypropofol
excreted in kidneys
Lidocaine is administered to?
1.Suppress coughing reflex during laryngoscopy
2.Reduce the airway responsiveness to noxious stimuli
3.Reduce pain caused by IV injection agents
Lidocaine dosing?
0.5-1mg/kg.
1mg/kg for induction
ERAS= 1-2 mcg/kg/hr
Which drug can attenuate the intracranial hypertensive response to laryngoscopy?
Lidocaine
Synthetic Piperidine
High volume of distribution in lipohillic opiods, low protein binding.
100x more potent than morphine
Metabolized by liver.
0.5-1mcg/kg (50-100mcgs) typically
Fentanyl
Which Opiod receptors does Fentanyl affect?
Mu-1
Mu-2
Kappa
Which opiod receptor affects?
Supraspinal analgesia
Bradycardia
Sedation
Pruritus
N/V
Mu-1
Morphine
Meperidine
Fentanyl
Which opiod receptor affects?
Respiratory depression
Euphoria
pruritis
constipation
dependence
Mu-2
Morphine
Meperidine
Fentanyl
Which opiod receptor affects?
Spinal analgesia
Respiratory depression
Sedation
miosis
Kappa
Fentanyl
Morphine
Nalbuphine
Which opiod receptor affects?
Spinal analgesia
Respiratory depression
Delta
Oxycodone
beta-endorphin
Leu-enkephalin
Noncompetitive NMDA receptor antagonist that blocks glutamate?
Phencyclidine derivative
Inhibits the re-uptake of Norepinephrine
Causes dissociative anesthesia
Given for induction, sedation, trauma, CV collapse.
Causes increase in BP, HR, CO, CVP, CI
Minimal respiratory depression, maintains airway reflexes, increased oral secretions, Bonchodilator
Emergence delirium (give versed)
Ketamine
Which opiod receptors does ketamine affect?
Kappa-agonist
Mu-antagonist
Increase in ICP, CBF, CMRO2,
Norketamine is active metabolite (1/3) potency.
Ketamine
Ketamine Dosing?
Onset?
Duration?
1-2mg/kg IV
4-5mg/kg IM
Onset-30 secs, IM-2 mins
Duration 10-15 mins
Short acting barbiturate
Activates GABA
Used in sedative, hypnotic, anticonvulsant, treatment of ICP in neuro cases.
Histamine release
Decrease CBP/ICP, hypotension.
No longer in the US
Thiopental
Short acting Barbiturate contraindicated in Acute Intermittent Porphyria (AIP).
Dosing 3-5 mg/kg IV
Onset- 30 secs
Duration- 5-30 mins
Hepatic metabolism
Thiopental
Ultrashort acting non-barbiturate hypnotic depressant RAS.
Affects GABA
used for induction or procedural sedation
Minimal CV effects, Minimal respiratory depression
Myoclonic Movements
Adrenocortical suppression (long-term)
Etomidate
Etomidate dosing?
Onset?
metabolism?
0.2-0.3 mg/kg
30-60 secs
Hepatic enzyme and plasma esterase hydrolysis
Highly selective, potent central acting Alpha-2 adrenergic agonist.
Inhibition of norepinephrine release presynaptically.
Used in procedure sedation, analgesia, fiberoptic intubation, post-op sedation.
Bradycardia/Hypotension
Minimal respiratory depression.
Dexmedetomidine
Dexmedetomidine dosing?
Onset?
Duration?
Excretion?
Procedural sedation: 0.5-1mcg/kg over 10 mins
IV infusion 0.3-0.7mcg/kg/hour.
5-10 min onset
duration 1 hour
Hepatic metabolism/urine excretion
Rapid ultrashort acting barbiturate, enhances GABA affect.
Uses: ECT, ENDO, Short
Deep sedation, skeletal muscle hyperactivity
Lowers seizure threshold
Methohexital
Methohexital Dose?
Onset?
Duration?
1-1.5mg/kg.
Onset 30 secs
Duration 5-7 mins
Hepatic metabolism, urine excretion
3 ways to cause muscle relaxation?
- High dose volatile anesthetics
- Regional anesthesia
- NMBA
Depolarizing NMBA?
Succinycholine
Non-depolarizing aminosteroids?
Rocuronium
Vecuronium
Pancuronium
Non-depolarizing Benzylisoquinolines?
Cisatricurium
Atracurium
Mivacurium
Binds to 2 alpha subunits of nicotinic cholinergic receptors, allows Na and Ca influx, K efflux.
Depolarization of muscle
remains depolarized until SCH diffuses away from the receptor.
Succinycholine
What does Succinycholine mimic?
Acetycholine
Used in RSI, very short cases, and laryngospasm?
Succinycholine
Side effects of Succinycholine?
Hyperkalemia + 0.5mg
Malignant hyperthermia
Minimal histamine release
Decreases HR
Fasciculations
Myalgias
Succinycholine metabolism?
Butrycholinesterase/plasma cholinesterase in the plasma hydrolyzed. Succinymonocholine weak active metabolite.
Decreased levels of pseudocholinesterase can prolong the block.
Succinycholine dosing?
Onset?
Duration?
1-1.5 mg/kg
30-60 sec onset
<10 min duration
Malignant hyperthermia triggers?
First sign to look out for?
Succinycholine and volatile anesthetics
Increased etCO2
How do nondepolarizing muscle relaxants work?
Compete with/ block acetycholine at the nicotinic receptor alpha subunits on the motor endplate.
Aminosteroids metabolism?
Hepatic breakdown, kidney excretion, minimal histamine release.
Potential for allergic reactions
Intermediate action, rare histamine release, nondepolarizing NMBA.
Used to defasciculate with Sux.
No effect on BP or HR
Aminosteroid
Rocuronium
Rocuronium dose?
Maintenance dose?
Onset?
Duration?
0.6mg/kg induction
1.2mg/kg RSI
5mg defasciulating dose
0.1mg/kg repeat/maintenance
1-2 min onset
30 min duration
Intermediate nondepolarizing NMBA, no histamine release, cardiac stable.
Precipitate with thiopental.
Vecuronium
Pancuronium dosing
onset?
Duration?
.08-.12 mg/kg
2-3 min onset
60-100 min duration
Vecuronium Dosing?
Onset?
Maintenance?
0.08-0.1mg/kg
2-3 min onset
0.01 mg/kg maintenance
Increased Hoffman elimination is caused by?
Increased pH and temperature
This benzylisoquinoline has histamine release when given quick. Hydrolysis by plasma cholinesterase?
Dose 0.2mg/kg
1 min onset
Mivacurium
Elimination for Benzylisoquinolines?
Hoffman Elimination and ester hydrolysis
Decresased Hoffman elimination is caused by?
Decreased pH and temperature
Long acting aminosteroid NMBA,
No histamine release
Tachycardia due to norepi release
Increase in BP and CO
Pancuronium
Intermediate acting Benzyliso NMBA, small histamine release. Minimal decrease in BP. Primary metabolite is Laudanosine which can produce seizure activity. Tertiary amine.
Atracurium
Atracurium dosing?
Onset
Duration
0.3-0.6mg/kg
2-3 min onset
20-30 min duration
Intermediate/ long acting Benzylisoquionlone NMBA.
No histamine release, No changes in BP/HR.
Cisatricurium
Cisatricurium dosing?
Onset?
Duration
0.1-0.15 mg/kg IV dose
2-3 min onset
40-70 min duration
Most allergic reactions are caused by which 2 drugs?
Sugammadex-32%
Rocuronium-27%
Which factors affect reversal of NMBA?
Intensity of block
Dose and choice of NMB
Drug interactions
Choice of reversal agent
Disease process (Liver faliure)
Blocking or inhibiting the breakdown of ACH at the NMJ results in an _____ in the avaliable pool of ACH at the synaptic cleft and a better change of competing with the nondepolarizing NMBA.
Increase
Side effect of Acetycholinesterase inhibitors?
SLUDGE
muscarinic stimulation
Increased bronchial secretions/bronchospasm
Bradycardia
Treatment for overdose of anticholinergic agent?
Physostigmine, increases Ach amount
tertiary amine that crosses the BBB.
Inhibits hydrolysis of ACh by AChE.
Causes parasympathetic affects, used with glycopyrrolate to decrease muscarinic side effects.
Quaternary ammonium.
Ceiling affect.
used in deep blocks.
Neostigmine
Neostigmine dosing?
70mcg/kg max dose
5mg
This drug is used with atropine due to rapid onset and decrease in HR. Inhibits destruction of ACh by AChE.
Dose 0.5-1mg/kg Quarternary amine
Edrophonium
Enlon-plus is a mixture of Edrophonium and atropine together. Dose?
.05-.1 mg/kg slowly over 1 min
Inactivation of acetycholinesterase
Overstimulation of nicotinic and muscarinic receptors.
Symptoms include SLUDGE, MTWTF
Cholinergic Syndrome
Cholinergic Crisis
Treatment of Cholinergic Crisis?
Pralidoxime obidoxime.
Give atropine as needed for HR
Tertiary amine, only cholinesterase that crosses blood brain barrier.
Not used for reversal of muscle relaxants. used to treat anticholinergic toxicity.
Physostigmine
Used for the reversal of rocuronium and vecuronium.
Selective relaxant binding agent that encapsulates to prevent action.
Sugammadex
Sugammadex dosing?
2mg/kg for TOF of 2
4mg/kg for no twitches
16mg/kg to reverse RSI dose
16mg/kg for rocuronium only
Precautions with sugammadex use?
Anaphlyaxis, Bradycardia, risk of coagulopathy and bleeding (increase PTT).
Reverse Hormonal contraceptive, no sex for 7 days
Competitive Acetylcholine antagonist.
Tertiary amine
Used for reversal, brady arrhythmias,
Careful use with narrow angle glaucoma. Crosses placenta
Atropine
Atropine dose?
onset
duration
0.2-0.4mg
30 seconds onset
up to 30 min duration
Synthetic antimuscarinic, competitive Ach antagonist.
Used with neostigmine for reversal agent.
Antisialogogue and increase HR.
Quarternary Ammonium
Glycopyrrolate
Glycopyrrolate dose?
onset
duration
0.2mg per 1 mg Neo. Max 1mg
1 min onset
2-4 hours duration
Competitive antagonist of AcH at muscarinic receptors. Antagonize histamine and serotonin.
Tertiary amine.
Decreases secretions, PONV, motion sickness, vertigo, dilate pupils
Scopolamine
Which drug can lead to toxic psychosis in elderly and restlessness affects.
Scopolamine- do not touch eyes
Scopolamine dosage?
Transdermal patch-1.5mg
0.3-0.5mg IV or IM
Scopolamine overdose treatment?
Physostigmine or benzos.
Mixed-acting synthetic non-catecholamine sympathomimetic.
Indirect effect @ Alpha-1 and Beta-1 receptors to release norepi.
Direct effect @ Beta-2 to increase HR, CO and SVR.
Ephedrine
Increases BP/HR, CO and bronchodilator effect.
Contraindicated in MAOI pheochromocytoma.
Tachyphylaxis
Ephedrine
Tachyphylaxis?
Depletion of presynaptic norepinephrine, have to increase dose of drug to see any affect.
Ephedrine dose?
5-10 mg
Directly stimulates alpha-1 receptors and has minimal effect on Alpha-2 or Beta receptors.
Used for hypotension and patients with LV dysfunction.
OB choice Vasopressor
Phenylephrine
Which drug causes vasoconstriction to increase BP, reflex decrease in HR and increase coronary blood flow.
Phenylephrine
Phenylephrine dose?
50-100 mcg titration
Which drug is double diluted prior to administration?
Phenylephrine
0.1cc + 9.9cc NS
Ephedrine vs Neo in OB?
Ephedrine causes fetal tachycardia and acidosis.
Neosynephrine faster onset, shorter duration and maintains fetal pH.
This drug has a Nonselective Beta affect on Beta-1 (decrease HR and contract) and Beta-2 (vasodilation). It is selective Alpha-1 adrenergic antagonist (arterial vasodilation)
1A:7B blockade effect
Contraindicated in bronchospastic
Labetalol
The BP reduction in labetalol is caused by what?
Decreased PVR which can depress cardiac contractility
Labetalol dose?
Onset
Duration
5-20mg IV boluses
1-2 min onset
6 hour duration
This drug is a rapid-onset and short acting Selective Beta-1 antagonist(decrease HR). Used to treat tachycardia.
Contraindicated in bradycardia or CHF, heart block.
Metabolized by plasma esterases
Esmolol
Esmolol dose?
Onset
Duration
10mg bolus IV
Infusion of 50 mcg/kg/min
Rapid onset
10 min duration
This drug is a nonselective Beta-1 and Beta-2 antagnoist. Used for HTN, acute MI, Pheochromocytoma and anxiety.
Decrease BP due to decreased HR, CO, and contractility.
Contraindicated in Bronchospastic or AV block.
Propanolol
Propanolol dose?
Onset
Duration
1-3mg IV
2-3 min onset
4-6 hour duration
This drug is a selective Beta-1 adrenergic antagonist. Prevents inotropic and chronotropic responses to beta stimulation. Used for rapid HR and contractility control. Decrease BP.
Metoprolol
Metoprolol dose?
Half-life
1-5mg IV up to 15mg
3-4 hours half life
This drug is an antidiuretic hormone, released by posterior pituitary.
V1 effects(CV), V2 effects (Renal), V3 effects (pituitary). Used in sepsis, shock, hypotension secondary to ACE inhibitors refractory to catecholamine or sympathomimetics.
Potent Arterial Vasoconstrictor
Vasopressin
Vasopressin dose?
1-2 units bolus
This drug is a Direct systemic arterial vasodilator. Causes relaxation of arterial smooth muscle, blocks calcium release from SR. Decreases BP with increase in HR. Used in HTN, heart failure and eclampsia.
Contraindicated with CAD
Hydralazine
Hydralazine dose?
Onset
Duration
2.5-5mg IV q20min
15-30 min onset
4-6 hours duration
Risk factors for PONV?
Female(strongest)
Nonsmoker
Long procedures
GYN, ENT, Breast, Laproscopic procedures
Neostigmine, opiods
Prevention of motion sickness, NV. given to trauma patients, Transdermal patch, may have drying of secretions.
Visual disturbances due to anisocoria (unequal pupil size)?
Scopolamine
This drug is a Selective 5-HT3 receptor antagonist in the GI and chemoreceptor trigger zone.
Prevents N/V in patients.
Side effect: headache, diarrhea.
Careful use with prolonged QT interval
Zofran( Ondansetron)
Zofran dose?
Duration
4mg IV
4-6 hours
This drug is used for Nausea and vomiting prevention. Corticosteroid, lower surgical inflammation. Centrally inhibit prostaglandin synthesis and control endorphins.
Side effects: genital itching/burning
Careful in use with diabetics
Dexamethasone
Dexamethasone dose?
Duration
4-12mg IV
24 hour duration
Phenothiazine, H1 receptor antagonist (antihistamine). Anticholinergic action (motion sickness) D2 antagonist in CTZ. Used for N/V and anxiety. Can cause sedation, extrapyramidal symptoms.
Phenergan
Phenergan dose?
Onset
duration
12.5-25 mg IV
3-5 min onset
4-6 hour duration
This drug is a GI prokinetic, increases LES tone, enhances response to AcH in upper GI tract to increase Gastric motility.
Antiemetic due to dopamine agonist antagonism in chemoreceptor trigger zone. Crosses BBB
Can cause tardic dyskinesia, restlessness
Contraindicated in Bowel obstructions and parkinsons syndrome.
Can cause Neuroleptic Malignant Syndrome
Reglan (Metoclopramide)
Reglan dose?
Onset
Duration
5-10 mg IV
1-3 min onset
1-2 hours duration
This drug is an H2 receptor antagonist and inhibits gastric acid secretion.
Raises gastric pH
Given in preop
Pepcid (Famotidine)
Pepcid dosage?
Onset
20mg IV
30 mins onset
This drug blocks Ach in the vestibular apparatus and blocks H1 receptors in the solitary tract, antihistamine. Used to treat N/V.
Side effects: sedation and pain in injection.
Vistaril
Vistaril dose?
25mg mixed with ephedrine 25mg given IM 20 mins before end of surgery.
Used for induction of labor and control of postpartum uterine bleeding.
Indirectly increases intracellular calcium and directly stimulates the oxytocin receptor on the myometrium.
Contraindicated in fetal distress or previous uterine rupture.
Side effects: tachycardia
Oxytocin
Oxytocin dose?
Onset
Duration
10-40 units in 1L LR bolus
Immediate onset
1 hour duration
This drug is a semisynthetic ergot alkaloid, increases motor activity of uterus by acting directly on smooth muscle to increase contraction.
Arterial vasoconstriction by alpha stimulation.
Contraindicated in CAD, HTN
NEVER GIVE IV
Methergine
Methergine dose?
onset
duration
0.2mg IM q2hours
2-5 min onset
3 hour duration
Synthetic analogue of prostaglandin F2 that stimulates uterine contraction. Increases myometrial calcium, stimulates smooth muscle of GI tract.
Increase in temperature (2 degrees)
Airway constriction and wheezing
Do not give to Asthma history
Hemabate
Hemabate dose?
onset
duration
250 mcg IM
Immediate onset
2 hour duration
Synthetic prostaglandin E1
Indicated for uterine atony, abortions, and cervical ripening.
Given buccal, rectally, vaginally.
Misoprostol
Cytotec
Cytotec dose?
half life
1-2 tabs buccal 200mcg each
rectally or vaginally.
Half life 20-40 mins
This drug is used to prevent eclamptic seizures and stop premature labor. Inhibition of acetylcholine release at NMJ. MIld vasodilator that decreases uterine activity to increase uterine blood.
Can cause pulmonary edema
Monitor levels
Check deep tendon reflexes
Will cross placenta
Magnesium sulfate
Magnesium sulfate dose?
Onset
duration
4 grams over 20 mins
immediate onset
20-30 mins duration
What is used to treat magnesium toxicity?
Calcium gluconate 1 gram over 2 mins
Which drug is used for acute hypertensive crisis, potent arterial dilator, rapid onset and short duration. Maternal/fetal toxicity.
Nipride
This drug is a venodilator used to decrease cardiac filling pressures by acting on capacitance vessels and may get reflex tachycardia?
Nitroglycerine
This drug is a gabapentinoid, decreases hyperexcitability of dorsal horn neurons cause by tissue damage. Modulates calcium-induced release of glutamate in dorsal horn. Activation of descending noradrenergic pathway in spinal cord and brain?
Careful in old age and low GFR, OSA.
Gabapentin
Gabapentin dose
300-600mg PO
This drug is a selective COX-2 inhibitor, associated with increased risk of stroke, MI and worsening of HTN.
Avoid use in history of CAD or CVA?
Celebrex
Celebrex dose?
100-200mg
This drug is a central acting skeletal muscle relaxant, depresses the CNS and leads to muscle relaxation. Can cause hypotension, bradycardia if given rapidly. Avoid in patient with renal dysfunction?
Methocarbamol (Robaxin)
This drug is a non-selective COX 1 and COX 2 inhibitor. Prevents thromboxane synthesis. Decreases pain and cramping. Careful in use with elderly poor creatine clearance.
Ask surgeon before giving
Toradol
Toradol dosing?
Onset
Duration
15-30 mg IV q6h
10-30 min onset
4-6 hour duration
Samter’s triad is what?
- Asthma
- Nasal Polyps
- Aspirin Allergy
This is also called aspirin exacerbated respiratory disease. Chronic condition that includes 3 features. Acute reactions to aspirin and NSADS can be life threatening. Similar reaction to ETOH
Samter’s Triad
Non-opiod alternative given IV. Careful use in hepatic impairment and chronic alcoholics. Used in ERAS protocol to treat mild to moderate pain. Most common side effect is vomiting or headache.
Ofirmev
IV acetaminophen
Ofirmev dose?
onset
duration
1000mg IV over 15 mins q6h
Max of 4000mg
15 min onset
4-6 hours duration
This drug is given IV for pain control and must be diluted. Side effects are vomiting, headache and infusion site pain. Do not give to pregnant mothers or those with known hypersensitivity.
Caldolor
IV ibuprofen
Caldolor dose?
400-800mg over 30 mins
q6h
max dose of 3200mg
This drug is a potent MAOI which interacts with serotonin reuptake inhibitors. Can induce severe potentially fatal serotonin syndrome. Carefully given and make sure you have good working IV?
Methylene blue
Too much methylene blue can lead to what?
Serotonin syndrome.
Coma, confusion, agitation, hyperthermia, respiratory failure, brisk reflexes
This is given to visualize ureters during cystoscopy. Intraoperative urologic dye marker. Do not give to patient with bronchial asthma.
Dose?
Fluorescein dye
50-100 mg IV
This is an inactive blue dye routinely given IV during urologic and gynecologic surgeryes to localize ureteral orifices.
Can see hypertension
Can see increase BP with reflex decrease in HR.
Indigo Carmine
This is used for highlighting structures in robotic surgeries and tissue blood flow. Peak spectral absorption of 800nm.
Must be reconstituted.
Indocyanine green
2.5mg given
This drug is a Dopamine D2 antagonist
Used as an antipsychotic
Can prolong QTc,
0.5mg to 2mg IV.
Haloperidol
Haldol
This drug is a urinary alkalinizer typically used in OB as an antacid
30mL given 45 mins before C-section
Do not ive to renal patients or sodium restricted diets. Will raise pH of gastric acid.
Can also treat metabolic acidosis from renal patients.
Bicitra
This drug can be given from 0.5-10mcg/kg/min. Used to to stimulate dopaminergic alpha and beta adrenergic receptors.
Metabolized in liver and kidneys.
Half life -2 mins
Onset 5 mins
Contraindicated in pheochromocytoma, vfib, and asthma.
Dopamine
Dopamine Renal dose?
2-5 mcg/kg/min
Low dose
Dopamine Cardiac dose?
5-10 mcg/kg/min
Medium dose
Dopamine vasoconstriction dose?
10-20 mcg/kg/min
High dose
This drug is a titratable ionotropic agent used to increase HR, BP, CO and CVP by increase contractility.
Potent nonselective Beta-1 agonist.
Synethetic catecholamine sympathomimetic.
Half life-2 mins
Dose- 2.5-20 mcg/kg/min
Dobutamine
Remifentail maintenance dose?
.05-.10 mcg/kg/min
Sufentanil maintenance dose?
.025-0.15 mcg/kg/min