TOP OF THE CART DRUGS (ALL) Flashcards
SUBLIMAZE (FENTANYL) Dosages: Induction, Intraop, Pediatric, Epidural, Infusion, Post-op pain
Induction: 2-5mcg/kg Intraop: 2-20mch/g Pediatric: 1mcg/kg Epidural: 50-100mcg Infusion: 25-50mcg/hr Post-op pain: 0.5-1.5mcg/kg
SUBLIMAZE (FENTANYL) indication, mechanism of action
PAIN, Stimulates μ receptors, Activation of μ receptors opens potassium channels inhibiting action potentials from firing in pain pathways throughout the CNS
SUBLIMAZE (FENTANYL) concern/complication
Greatest risk for respiratory depression is during peak action. High doses = chest wall rigidity. Highly lipid soluble. 75% first pass pulmonary uptake
MIDAZOLAM (VERSED) Dosages: Premed, Sedation, Induction
Premed: 0.07-0.15 mg/kg
Sedation: 0.01-0.1 mg/kg
Induction 0.1-0.4 mg/kg
MIDAZOLAM (VERSED) Mechanism of action, indication
BENZODIAZEPINE, Binds to the alpha subunits on the GABA-A receptor and leaves chloride channels open which hyperpolarizes the postsynaptic cell within the cerebral cortex, cerebellar cortex, and thalamus.
MIDAZOLAM (VERSED) Concern/complication
pH dependent ring opening phenomenon in which the ring remains open at pH values <4 thus maintaining water solubility and closes at pH values >4 making it highly lipid soluble. Cleft palate in neonates.
LIDOCAINE correct dose
1-1.5 mg/kg
4mg/kg (300mg)
7mg/kg (500mg)
LIDOCAINE mechanism of action, indication
LOCAL ANESTHETIC Blocks Na channels from inside he cell membrane. Occlusion of open Na channels inhibits the Na permeability thus slowing the rate of depolarization. Interruption of pain signal transmission.
LIDOCAINE concern/complication
Infiltration 0.5-1%, IVRA 0.25-5%, Epidural: 1.5-2%, Spinal: 1.5-5%
DIPRIVAN (PROPFOL) induction and maintenance dose
1.5-2.0 mg/kg
100-300mcg/kg/min
DIPRIVAN (PROPFOL) MOA, indication
Induces GA by facilitating inhibitory neurotransmission by GABA-A receptors—binds to the beta subunit on the GABA-A receptors. Results in sedative/hypnotic effects. GABA-A receptors activated, transmembrane chloride conductance increased=hyperpolarized postsynaptic cell membrane and functional inhibition of postsynaptic neuron.
DIPRIVAN (PROPFOL) concern/complication
High lipid solubility. Discard 6 hours after opening. Pain with injection. Caution in the elderly and hypovolemic patients. Decreases ICP, CMRO2, and CBP.
SUCCINYLCHOLINE (ANECTINE) standard and spasm dose
1.0-1.5 mg/kg
Spasm: 0.25-1mg/kg
SUCCINYLCHOLINE (ANECTINE) mechanism of action, indication
Neuromuscular Blocking Agent, Depolarizing NMB attaches to one or both alpha subunits of the nAchRs and mimics action of Ach (partial agonist). Causes depolarization of the postjunctional membrane.
SUCCINYLCHOLINE (ANECTINE) concern/complication
Do not give if trauma is > 24 hours, Caution in renal failure due to increased K
ROCURONIUM (ZEMURON) standard, bolus, priming 10% ID dosages
0.6-1.2 mg/kg
Bolus 0.06-0.6 mg/kg
Priming 10% ID 0.5mg, give 3-5 min before intubation
ROCURONIUM (ZEMURON) mechanism of action, indication
NDMR quaternary amniosteroid, competes for cholinergic receptors at the motor end plate.
ROCURONIUM (ZEMURON) concern/complication
Onset time is decreased and DOA prolonged with increasing doses
CV stable, good for infusions (mix 200mg in 100mLD5W for 2mg/ml)
VECURONIUM (NORCURON) standard, bolus, gtt and priming 10% ID dosages
0.08-0.1mg/kg
Bolus 0.01-0.05mg/kg
Gtt 1-2mcg/kg/min
Priming 10% ID 0.5-1.0mg
VECURONIUM (NORCURON) mechanism of action, indication
Intermediate NDMR that competes with cholinergic receptors at the motor end plate. 1/3 as potent as pancuronium. Vagotonic effects can occur when combined with opioids.
VECURONIUM (NORCURON) concern/complication
Reconstitute with sterile water
Gtt 20 mg/100mL D5W for 0.2mg/mL
10mg of powder reconstituted with 10mL of saline
concentration: 1mg/mL
CISATRACURIUM (NIMBEX) standard, bolus, gtt, and priming dose
0.15-0.2mg/kg
Bolus 0.02-0.1mg/kg
Gtt 1-5mcg/kg/min
Priming 1-2mg
CISATRACURIUM (NIMBEX) mechanism of action, indication
Isomer of atracurium, competes for cholinergic receptors at the motor end plate.
CISATRACURIUM (NIMBEX) concern/complication
Laudenosine is a metabolite of metabolism that can cause seizures.
Histamine release can cause tachycardia, hypotension, bronch- and laryngospasm.
NEOSTIGMINE Reversal, max, w/atropine, w/ glycopyrrolate, MG Tx dose
Reversal 0.05mg/kg MAX DOSE 5mg With Atropine 0.015mg/kg With Glycopyrrolate 0.01mg/kg MG Tx 15-375mg PO QD
NEOSTIGMINE mechanism of action, indication
Reversal of NDMRs, treatment of MG, postoperative ileus, and urinary retention. Inhibits hydrolysis of acetylcholine by inhibiting achetylcholinesterase at the esteric site.
NEOSTIGMINE concern/complication
Cholinergic effects SLUDBBM
Cholinergic Crisis –> S/S: N/V, sweating, brady- or tachycardia, excessive salivation, sweating, bronchospasm, weakness, and paralysis. Treat with 10mcg/kg Atropine Q 3-10 min
GLYCOPYRROLATE (ROBINUL) dose with neostigmine or pyridostigmine
0.2mg for each 1mg of Neostigmine or 5mg of pyridostigmine
GLYCOPYRROLATE (ROBINUL) mechanism of action, indication
Quaternary ammonium anticholinergic. B/c of its polar nature it does not cross the BBB. It antagonizes muscarinic symptoms induced by cholinergic drugs. It produces less tachycardia than atropine.
GLYCOPYRROLATE (ROBINUL) concern/complication
Reduces LES tone, spincters in the GI tract are relaxed by nitric oxide that is released by the parasympathetic NANC fibers.
Can increase IOP—caution in pts with glaucoma. Use with caution in pts with BPH, MG, paralytic ileus, or ulcerative colitis. SEs orthostatic hypotension, dry mouth, and urine retention.
ATROPINE correct dose
- 01-0.02mg/kg
vial: 0.4mg/mL - 014 mg per mg of edtophonium
ATROPINE mechanism of action
Tertiary amine antimuscarinic It antagonizes muscarinic symptoms induced by cholinergic drugs. Tachycardia.
ATROPINE concern/complication
Crosses the blood/brain barrier; in large doses produces excitation/delirium. Can increase IOP—caution in pts with glaucoma. Use with caution in patients with BPH, MG, paralytic ileus, or ulcerative colitis
HYDROMORPHONE (DILAUDID) analgesic IV and PO, Spinal, Epidural infusion/bolus, and intrathecal dose
Analgesia 0.01-0.04mg/kg (0.5-2.0mg) Q4-6hr 2-4mg PO q4-6hr Spinal 0.1-0.2mg (2-4mcg.kg) Epidural Infusion 0.15-0.3mg/hr Epidural Bolus 1-2mg Intrathecal 0.1mg
concentration: 2mg/mL
HYDROMORPHONE (DILAUDID) mechanism of action, indication
Opiate agonists that is a hydrogenated ketone of morphine. 7x more potent than morphine. Effects on CNS and organs containing smooth muscle.
HYDROMORPHONE (DILAUDID) concern/complication
Can causes drowsiness, euphoria, resp depression, interference with adrenocortical response to stress at high doses. Releases histamine.
Prolonged analgesia by alpha agonists such as clonidine.
Reduce the dose in the elderly,
hypovolemic, or patients on other sedatives. Biliary smooth muscle spasm.
REMIFENTANYL (ULTIVA) Induction, Gtt, Bolus, MAC, MAC gtt dose
Induction 1mcg/kg over 30-60sec Gtt 0.5-4mcg/kg/min Bolus 1mcg/kg MAC 0.5-1mcg/kg over 30-60 sec MAC gtt 0.025-0.1mcg/kg/min *not recommended as sole agent*
REMIFENTANYL (ULTIVA) mechanism of action, indication
μ-opioid agonist with rapid onset and peak effect. Short DOA due to its metabolism by nonspecific plasma and tissue esterases. Recovery within 5-10 minutes and no residual analgesia.
REMIFENTANYL (ULTIVA) concern/complication
Decrease initial dose in elderly by 50%
Can increase does upward 25-100% and downward 25-50% every 2-5min due to its rapid onset and short DOA
CBF, ICP and CMRO2 decreased
Not used for spinal, epidural, or intrathecal—contains glycine
MORPHINE (DURAMORPH) premedication, intraop pain, postop pain, epidural and epidural infusion dose
Premedication 0.05-0.2mg/kg Pain intraop 0.1-1mg/kg Postop pain 0.03-0.15mg/kg Epidural 2-5mg Epidural infusion 0.3-0.9mg/hr
MORPHINE (DURAMORPH) mechanism of action, indication
Prototypical opioid agonist. Alkaloid of opium that exerts its effects on CNS and organs containing smooth muscle. N/V secondary to CTZ stimulation. Histamine release can cause pruritis.
MORPHINE (DURAMORPH) concern/complication
75-85% metabolized to morphine 3 glucuronide (inactive) but 5-10% metabolized to morphine-6-glucuronide (has analgesic and respiratory depression effects). Caution in ARF/CRF secondary to accumulation of metabolites and increased respiratory depression.
SUFENTANIL CITRATE (SUFENTA) Analgesia, induction, Gtt, epidural infusion, epidural gtt and spinal dose
Analgesia 0.2-0.3mcg/kg Induction 2.-10mcg/kg Gtt 0.1-0.5mcg/kg/min Epidural infusion 0.2-0.7mcg/kg Epidural Gtt 0.1-0.6mcg/kg/min Spinal 0.02-0.2mcg/kg
SUFENTANIL CITRATE (SUFENTA) mechanism of action, indication
Thienyl analogue of fentanyl with 5-7x the analgesic potency. Attenuates the hemodynamic response to DVL and surgical manipulation.
SUFENTANIL CITRATE (SUFENTA) concern/complication
Can cause dose dependent bradycardia. Highly lipophilic, crosses the placenta causing resp depression in fetus. Rapid redistribution terminates effects of small doses, but accumulates with larger doses
MEPERIDINE (DEMEROL) Analgesia, post-op shivering doses
Analgesia: 25-100mg
Post-op Shivering: 12.5-25mg
MEPERIDINE (DEMEROL) MOA, indication
Premedication, analgesia, and treatment of post-op shivering. Synthetic opioid agonist 1/10th as potent as morphine. Direct myocardial depressant at high doses
MEPERIDINE (DEMEROL) concern/complications
DO NOT GIVE WITH MAOI’S. Active metabolite NORMEPERIDINE can cause seizures
KETOROLAC (TORADOL) dose
15-30mg QID
KETOROLAC (TORADOL) MOA, indication
Analgesia. NSAID that has analgesia, anti-inflammatory, and antipyretic effects. 30mg is equivalent to 9mg morphine. Inhibits the synthesis of prostaglandins, no sedative effects. Peripheral analgesia
KETOROLAC (TORADOL) concern/complications
Caution in renal/hepatic insufficiency. Can cause HTN due to loss of prostaglandin synthesis. Do not use in pregnancy b/c it inhibits uterine contractions, affects fetal circulation (promotes closure of PDA), and is excreted in breat milk. Do not use with other NSAID’s of pt. with hx of GI bleed
ETOMIDATE (AMDIATE) induction, gtt doses
Induction: 0.1-0.4mg/kg
Gtt: 0.25-1mg/min
ETOMIDATE (AMDIATE) MOA, indication
Induction and supplementation of anesthesia. Nonbarbituate hypnotic. No analgesic effects. Can elicit alternation in SSEP’s. Minimal effects on BP make it a good choice to maintain CPP
ETOMIDATE (AMDIATE) concern/complication
Can cause adrenocortical suppression that can last 4-6 hours and is due to etomidate induced inhibition of 11-beta hydroxylase. 30-60% of myoclonus
KETAMINE (KETALAR) sedation/analgesia, induction, gtt, epidural dose
Sedation/analgesia: 0.5-1mg/kg
Induction: 1-2.5mg/kg
Gtt: 15-80mcg/kg/min
Epidural: 0.5mg/kg
KETAMINE (KETALAR) MOA, indication
Dissociative anesthetic, induction and maintenance of anesthesia. Useful in hypovolemic or high risk patients. Ideal for short procedures. A phencyclidine derivative that produces rapid acting dissociative anesthesia characterized by normal or enhanced skeletal tone, resp stimulation, and minimal resp depression. Antagonist effect on NMDA - long term excitatory effects of nociceptive transmission
KETAMINE (KETALAR) concern/complications
CBF, CRMO2, and ICP are increased. Increased EEG activity. Increased salivary and tracheobronchial secretions. Emergence delirium. Disconjugate eyes, and SNS effects from indirect NE release - HTN. Decreases VA’s
ESMOLOL (BREVIBLOC) loading, bolus, Gtt, HTN, HTN Gtt doses
Loading: 0.5mg/kg Bolus: 0.2-0.5mg/kg (5-10mg) Gtt: 50-200mcg/kg/min HTN: 0.5-2mg/kg (repeat Q5min) HTN Gtt: 50-300mcg/kg/min
ESMOLOL (BREVIBLOC) MOA, indication
Treatment of SVT and HTN. Cardioselective beta blocker with rapid onset and short DOA. At high doses can effect beta-2 receptors
ESMOLOL (BREVIBLOC) concerns/complications
hypotension, bradycardia
LABETALOL (NORMODYNE, TRANDATE) dose, Gtt, max cumulative dose
Single Dose: 2.5-20mg (over 2min)
Gtt: 0.5-2mg/min
Cumulative Dose: 1-4mg/kg
LABETALOL (NORMODYNE, TRANDATE) MOA, indications
Nonselective adrenergic receptor blocking agent with mild alpha, and predominant beta activity (Alpha:Beta = 1:7 (IV), 1:3 (PO)). Decreased BP with minimal risk of reflex tachycardia. Risk of bronchospasm
LABETALOL (NORMODYNE, TRANDATE)
Crosses placenta
PHENYLEPHRINE dose
0.5-1mcg/kg
50-100mcg bolus
PHENYLEPHRINE MOA, indication
Direct alpha-1 agonist, produces intense peripheral vasoconstriction, increased SBP & DBP, reflex bradycardia can result in decreased CO. Increased SVR can aid in reducing R-L shunt in Fallot
PHENYLEPHRINE concern/complications
Tachyphylaxis may occur
EPHEDRINE dose, max dose
2.5-10mg
150mg/24 hours
EPHEDRINE MOA, indications
Vasopressor, bronchodilator. Noncatecholamine sympathomimetic with mixed direct and indirect actions. Resistant to MAO and COMT resulting in longer DOA. Increases CO, BP and HR by alpha and adrenergic stimulation. Increases coronary and skeletal blood flow, bronchodilation by beta-2 receptor stimulation. Restores uterine blood flow when used to treat epidural/spinal hypotension.
EPHEDRINE concern/complications
Tachyphylaxis may occur once catecholamine stores are depleted
ONDANSETRON (ZOFRAN) dose
4mg Q4-8hr
ONDANSETRON (ZOFRAN) MOA, indication
Selective serotonin 5HT3 antagonist, receptors are found peripherally on vagal nerve terminals and centrally in the CTZ. Prevention and treatment of chemo induced and post-op N/V
ONDANSETRON (ZOFRAN) concerns/complications
Expensive
DEXMEDETOMIDINE loading, Gtt dose
Loading: 1mcg/kg over 10min
Gtt: 0.2-0.7mcg/kg/hr
DEXMEDETOMIDINE MOA, indications
Selective alpha-2 adrenergic agonist. Binding in the locus ceruleus produces sedation and binding in the spinal cord produces analgesia
DEXMEDETOMIDINE concern/complications
Does not decrease resp drive or CRMO2: may decrease cerebral arterial responsiveness to CO2 changes.; bradycardia and hypotension are common side effects; HTN may be seen with rapid admin of large dose due to spillover of alpha-1 adrenergic receptors.
PROMETHAZINE HYDROCHLORIDE (PHENERGAN) dose
12.5-50mg Q4-6hr
PROMETHAZINE HYDROCHLORIDE (PHENERGAN) MOA, indications
Phenothiazine derivative, does not possess neuroleptic or antipsychotic activity. H1 receptor antagonist with sedative, antiemetic, and anti-motion sickness effects
PROMETHAZINE HYDROCHLORIDE (PHENERGAN) concern/complications
EPS symptoms may occur. DO NOT USE WITH EPI TO TREAT HYPOTENSION, PHENOTHIAXINES CAUSE A REVERSAL OF EPI’S VASOPRESSOR EFFECTS AND CAUSE FURTHER DECREASES IN BP. USE NE OR NEO
DEXAMETHASONE (DECADRON) dose
4-8mg IV
DEXAMETHASONE (DECADRON) MOA, indications
Corticosteroid- potential anti-inflammatory agent. Treatment of inflammatory diseases, cerebral edema, raised ICP, airway edema, aspiration pneumonitis, bronchial asthma, myofascial pain, allergic rxn, prevention of rejection of organ transplant, replacement therapy for adrenocortical insufficiency
DEXAMETHASONE (DECADRON) concern/complication
Does not cause Na/H2O retention, caution in DM. HPA axis suppression
SUGGAMADEX (ORGANON) dose
2-4mg/kg IV
SUGGAMADEX (ORGANON) MOA, indications
SRBA’s (selective relaxant binding agents)
•Binds steroidal MR (Roc>Vec»Panc)
•Forming water soluble complex in plasma
•Markedly enhances conc. gradient b/t plasma & synapse
Terminates NMB rapidly by enhanced diffusion of drug away from NMJ
SUGGAMADEX (ORGANON) concern/complication
Women who use OCPs must be advised to used alternative BC method (condoms, abstinence, etc) for 7 days after suggamadex •Approximately 0.004% of patients may suffer anaphylaxis (genetically moderated, with highest rate to rocuronium
•May prolong coagulation at highest doses (16 mg/kg), but clinical significance of this effect remains unclear •Will antagonize subsequent aminosteriod blockade until excreted renally (give succinylcholine or cisatracurium)
EPINEPHRINE dose
Infusion: 16mg/500ml =32ug/ml
Start at 2ug/min
2 times 60 =120ug/hr
120ug divided by 32ug/ml =3.75ml/hr
EPINEPHRINE MOA, indications
Low dose (2-10 mcg/min) stimulate adrenergic beta 1 and beta 2 receptors Increases HR, CO, contractility, conduction bronchodilaton
High doses ( >10 mcg/min) stimulate adrenergic alpha receptors Vasoconstriction of skin, mucosa, and renal vascular beds
EPINEPHRINE concern/complication
Complications: Cerebral hemorrhage (from increased BP), CNS disturbances, pulmonary edema, coronary ischemia, ventricular dysrhythmias (potentiated by halothane)
Hyperglycemia
Hypokalemia - drives K+ into skeletal muscle cells (usually mild).
increases Factor V, accelerating coagulation
METOCLOPRAMIDE (REGLAN) Dose
Dosing ( comes as 10mg/ml )
10 mg IV over 1-2 mins in adults
May repeat X 1 (up to 20 mg)
METOCLOPRAMIDE (REGLAN)
MOA, indications
D2 receptor antagonist and Cholinergic receptor agonist
Physiologic effects
Gastric motility in upper GI tract
LES tone by 10-20 cm
Uses
- Prokinetic
- Aspiration prophylaxis
Not an effective antiemetic
METOCLOPRAMIDE (REGLAN)
concern/complication
Contraindications
- Pediatric population
- Pheochromocytoma
- Bowel obstruction
- Parkinson’s disease
- Avoid w/ MOAs
SCOPOLAMINE Dose
0.2-0.65 mg IV/IM/SC
Children 0.006 mg/kg
Patch 1.5 mg applied 1-4 hrs pre-op
Remove between 24 to 72 hrs after surgery
SCOPOLAMINE MOA, indications
Muscarinic cholinergic receptors antagonist
gastric acid secretion, gastrointestinal motility, and LES tone
SCOPOLAMINE concern/complication
Crosses BBB
Side effects
- Sedation
- Dry mouth
- Urinary retention
- Blurred vision
- Confusion/anxiety
- Central anticholinergic syndrome
