Top Drawer- S3 Flashcards by Brad Koester

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

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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

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Contraindications to Propofol?

Egg or soy allergies?
Patients with low CO or hypovolemia.
Will decrease HR and BP even more

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Propofol dosing?
INDUCTION
MAC/MAINTENANCE

Propofol onset
Propofol Duration

Induction=2mg/kg

MAC=25-200mcg/kg/min

Onset= 30secs rapid
Duration= Dose dependent

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Propofol metabolism?

In the liver to 4-hydroxypropofol
excreted in kidneys

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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

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Lidocaine dosing?

0.5-1mg/kg.
1mg/kg for induction
ERAS= 1-2 mcg/kg/hr

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Which drug can attenuate the intracranial hypertensive response to laryngoscopy?

Lidocaine

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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

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Which Opiod receptors does Fentanyl affect?

Mu-1
Mu-2
Kappa

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Which opiod receptor affects?
Supraspinal analgesia
Bradycardia
Sedation
Pruritus
N/V

Mu-1

Morphine
Meperidine
Fentanyl

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Which opiod receptor affects?
Respiratory depression
Euphoria
pruritis
constipation
dependence

Mu-2

Morphine
Meperidine
Fentanyl

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Which opiod receptor affects?
Spinal analgesia
Respiratory depression
Sedation
miosis

Kappa

Fentanyl
Morphine
Nalbuphine

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Which opiod receptor affects?
Spinal analgesia
Respiratory depression

Delta

Oxycodone
beta-endorphin
Leu-enkephalin

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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

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Which opiod receptors does ketamine affect?

Kappa-agonist
Mu-antagonist

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Increase in ICP, CBF, CMRO2,
Norketamine is active metabolite (1/3) potency.

Ketamine

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Ketamine Dosing?
Onset?
Duration?

1-2mg/kg IV
4-5mg/kg IM

Onset-30 secs, IM-2 mins
Duration 10-15 mins

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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

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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

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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

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Etomidate dosing?
Onset?
metabolism?

0.2-0.3 mg/kg
30-60 secs
Hepatic enzyme and plasma esterase hydrolysis

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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

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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

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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?

1. High dose volatile anesthetics 2. Regional anesthesia 3. 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?

1. Asthma 2. Nasal Polyps 3. 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