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Nurs 575 Anesthesia Pharmacology > Week 6 Antiemetics/Prokinetics/Antihistamines/serotonins > Flashcards

Week 6 Antiemetics/Prokinetics/Antihistamines/serotonins Flashcards

1
Q

Without prophylaxis, nausea occurs in up to ________ of patients who undergo general anesthesia, but can be as high as ________ in high risk patients

A
  • 40%
  • 80%

Stoelting’s, pg. 692

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2
Q

PONV can be further classified as early or late - what time frames align with each classification?

A
  • Early: within 6 hours of emergence
  • Late: 6-24 hours after

Stoelting’s, pg. 692

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3
Q

PONV can be associated with increased morbidity due to:

A
  • dehydration
  • electrolyte abnormalities
  • wound dehiscence
  • bleeding
  • esophageal rupture
  • airway compromise

Stoelting’s, pg. 692

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4
Q

__________ is the muscular contractions within the ileum and jejunum that moves luminal contents back towards the stomach

A
  • antiperistalsis

Stoelting’s, pg. 692

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5
Q

The sequence of events that occur during emesis are controlled by the so-called vomiting “center”, which lies in the ______________

A
  • medulla oblongata

Stoelting’s, pg. 692

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6
Q

Name several of the neurotransmitters that modulate the activity of the vomiting center

A

Stoelting’s, pg. 692 - Fig 34-1

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7
Q

Slightly cephalad to the vomiting center is the _____________, which detects noxious stimuli in the bloodstream

A
  • Chemoreceptor trigger zone

Stoelting’s, pg. 693

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8
Q

What other anatomic sites (besides the CTZ) can activate the vomiting center?

A
  • vestibular apparatus
  • thalamus
  • cerebral cortex
  • neurons within the GI tract itself

Stoelting’s, pg. 693

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9
Q

Upon activation, the vomiting center sends efferent signals via which cranial nerve(s)?

A
  • 5 - trigeminal
  • 7 - facial
  • 9 - glossopharyngeal
  • 10 - vagus
  • 12 - hypoglossal

Stoelting’s, pg. 693

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10
Q

What patient factors are associated with an increased risk of PONV?

A
  • female gender (effects of progesterone/estrogen on CTZ/vomiting center)
  • nonsmoker
  • history of motion sickness or PONV

Stoelting’s, pg. 693

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11
Q

Among adults, the risk for PONV is ___________ with aging

A
  • reduced

Stoelting’s, pg. 693

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12
Q

What surgical factors are associated with increased risk for PONV?

A

Longer procedures

Type of procedure

  • laparotomy & laparoscopic
  • gynecologic
  • ENT
  • breast
  • ortho

Stoelting’s, pg. 693

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13
Q

What anesthetic factors are associated with an increased risk for PONV?

A

The use of:

  • nitrous oxide
  • neostigmine
  • opioids

Stoelting’s, pg. 693

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14
Q

_____________ is a transdermal anticholinergic that can be used for the prevention of PONV

A
  • scopolamine

Stoelting’s, pg. 693

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15
Q

Due to it’s onset of action, scopolamine is most effective when administered _________ before noxious stimuli

A
  • 4 hours

Stoelting’s, pg. 694
Nagelhout, pg. 211

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16
Q

How long can a scopolamine patch remain in place?

A
  • 24-72 hours

Stoelting’s, pg. 694

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17
Q

True or false:

Transdermal scopolamine provides sustained therapeutic plasma concentrations, usually WITHOUT producing the prohibitive side effects such as sedation, cycloplegia (mydriasis/visual disturbances), or drying of secretions

A
  • True

Stoelting’s, pg. 694

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18
Q

Transdermal scopolamine exerts significant antiemetic effects in patients being treated with ____________ or ____________ for postoperative pain

A
  • PCA
  • epidural morphine

appears most effective for these indications

Stoelting’s, pg. 694
Nagelhout, pg. 211

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19
Q

Which two anticholinergics may decrease barrier pressure and increases the reflux of acidic fluid into the esophagus?

A
  • atropine (0.6 mg IV)
  • glycopyrrolate (0.2-0.3 mg IV)

Stoelting’s, pg. 695

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20
Q

__________ and __________ may enter the CNS and can produce symptoms of central anticholinergic syndrome

A
  • scopolamine
  • atropine

Stoelting’s, pg. 694

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21
Q

What are the symptoms of central anticholinergic syndrome?

A

Symptoms may range from:

  • restlessness & hallucinations
    to
  • somnolence & unconsciousness

Stoelting’s, pg. 694

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22
Q

Central anticholinergic syndrome is often mistaken for _____________ as ventilation may be depressed

A
  • delayed recovery from anesthesia

Stoelting’s, pg. 694

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23
Q

______________ is a lipid-soluble anticholinesterase that can be administered as a treatment for central anticholergic syndrome or anticholinergic overdose

A
  • Physostigmine (15-60 mcg/kg)

Stoelting’s, pg. 694-695

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24
Q

Symptoms of anticholinergic overdose may include:

A
  • dry mouth
  • difficulty swallowing or talking
  • blurred vision/photophobia
  • tachycardia
  • dry/flushed skin
  • increased body temperature (inhibition of sweating)

Stoelting’s, pg. 694-695

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25
Q

This benzamide is a weak antiemetic that also stimulates the GI tract via cholinergic mechanisms (increased gastric/small intenstine motility)

A
  • Metoclopramide

Stoelting’s, pg. 695

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26
Q

In addition to it’s peripheral effect in the GI tract, metoclopramide readily crosses the blood-brain barrier and may act directly on the CTZ via its __________ effects - this makes it contraindicated in patients with ____________ disease

A
  • anti-dopaminergic
  • Parkinson’s (or any disease related to dopamine inhibition or depletion)

Stoelting’s, pg. 695

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27
Q

Akathisia is a feeling of unease or restlessness in the lower extremities that may occur following the IV administration of _____________

A
  • Metoclopramide

may be so severe that it results in cancellation of the surgery

Stoelting’s, pg. 695

28
Q

What is the mechanism by which metoclopramide exerts its prokinetic effect? Antiemetic?

A
  • enhances cholinergic activity on GI smooth muscle
  • antagonism of dopamine at the CTZ

Stoelting’s, pg. 711

29
Q

Administration of metoclopramide __________ mg IV may be useful to speed gastric emptying before the induction of anesthesia

30
Q

How and when should Metoclopramide be given?

A
  • Pre-op, About 15-30 min before
  • 10-20mg over 3-5 min
31
Q

More rapid IV administration of metoclopramide may produce _____________

A
  • abdominal cramping

Stoelting’s, pg. 711

32
Q

The activity of the benzodiazepines, such as midazolam, may decrease the synthesis and release of _____________ within the CTZ as well as reducing the release of serotonin

A
  • dopamine

midazolam may be administered near the end of surgery for patients at risk of PONV who have not already received one as part of the anesthetic plan

Stoelting’s, pg. 695
Nagelhout, pg. 211

33
Q

The black box warning for droperidol is due to its association with _______________

A
  • prolonged QT syndromes

Stoelting’s, pg. 695

34
Q

The black box warning for droperidol was associated with doses much higher than necessary for the treatment of PONV - what dose is effective for the prevention and treatment of PONV?

A
  • 0.625-1.25 mg IV near the end of surgery

Stoelting’s, pg. 696
Nagelhout, pg. 211

35
Q

Because it’s mechanism of action is _____________, droperidol should be used with caution, if at all, in patients with ______________

A
  • anti-dopaminergic
  • Parkinson’s (or any disease related to dopamine inhibition or depletion)

Stoelting’s, pg. 696

36
Q

This corticosteroid has efficacy similar to ondansetron and droperidol

A
  • Dexamethasone

Stoelting’s, pg. 696

37
Q

True or false:

Dexamethasone has a minimal side effect profile with one-time use and decreases the risk for perioperative hyperglycemia for obese and diabetic patients

A
  • False - it does have a minimal side effect profile, but INCREASES the risk for hyperglycemia in these patients

avg increase of 40 mg/dL 6-12 hrs postop, no effects on wound healing

Stoelting’s, pg. 696
Nagelhout, pg. 209

38
Q

A ________ mg dose of dexamethasone is popular for the prevention of PONV - It is best given prior to or after the induction of general anesthesia (as opposed to at the end of surgery) because it’s onset of action is __________

A
  • 4-8 mg
  • 1 hour

Nagelhout, pg. 209

39
Q

What is the mechanism of action for drugs like ondansetron and granisteron?

A
  • 5-HT3 receptor antagonism
  • serotonin acts on 5-HT3 receptors on enteric neurons in the GI tract and brain to stimulate vagal afferents and the vomiting reflex

Stoelting’s, pg. 696

40
Q

True or false:

The serotonin receptor antagonists are not effective at treating motion-induced or vestibular PONV and they do not cause the same CNS effects as droperidol and metoclopramide

A
  • True - no 5-HT3 receptors in the vestibular apparatus; no action on dopamine, histamine, or cholinergic receptors

Stoelting’s, pg. 696

41
Q

What is the typical dosing strategy for ondansetron in the prevention/treatment of PONV

A
  • 4-8 mg IV over 2-5 minutes before induction or prior to the end of surgery
  • also listed as effective when administered orally

consider it’s duration of action (4-6 hrs) when timing dose

Stoelting’s, pg. 697

42
Q

What side effects are associated with the use of 5-HT3 receptor antagonists?

A
  • headache
  • diarrhea
  • QTc prolongation
  • serotonin syndrome

Stoelting’s, pg. 696-697

43
Q

Granisetron is _________ selective 5-HT3 receptor antagonist than ondansetron, with a ___________ duration of action

A
  • more
  • longer

may be efective for 24 hours

Stoelting’s, pg. 697

44
Q

Non-specific antihistamines such as __________, likely act on H__ receptors

A
  • diphenhydramine, dimenhydrinate, promethazine
  • 1

Stoelting’s, pg. 697

45
Q

What is the mechanism of action of antihistamines in the prevention of nausea and vomiting

A

Prevents GI smooth muscle contraction
Prevents secretion of acid in the stomach
Prevents release of neurotransmitters in the CNS

Stoelting’s, pg. 697, 700

46
Q

Dimenhydrinate is a ____________ used for PONV in adults - standard dose is __________

A
  • Non-specific antihistamine
  • 20 mg IV

Stoelting’s, pg. 697

47
Q

Which generation of H1 antagonists is more likely to cause CNS side effects such as somnolence?

A
  • 1st generation (diphenhydramine, dimenhydrinate)

Stoelting’s, pg. 701

48
Q

True or false:

1st generation histamine type 1 receptor antagonsits have a cross-reactivity with muscarinic receptors and thus exert anticholinergic effects such as dry mouth, blurred vision and urinary retention

A
  • True

Stoelting’s, pg. 703

49
Q

What cardiovascular side effect is common with 1st generation antihistamines?

A
  • tachycardia

Stoelting’s, pg. 703

50
Q

In children, a _________ dose of IV dimenhydrinate significantly reduces vomiting after strabismus surgery

A
  • 0.5 mg/kg

Stoelting’s, pg. 697

51
Q

True or false:

Antihistamines exert their effects by preventing the release of histamine

A
  • False - they are histamine receptor antagonists

Stoelting’s, pg. 701

52
Q

Factors associated with pulmonary complications of aspiration include the ___________ and __________ of the aspirated gastric contents

A
  • volume
  • acidity

Stoelting’s, pg. 699

53
Q

Antacids act by either ____________ hydrogen ions or ____________ of hydrogen chloride into the stomach

A
  • neutralizing
  • decrease the secretion

Stoelting’s, pg. 699

54
Q

___________ antacids are less likely to cause foreign body reactions if aspirated

A
  • Nonparticulate

Stoelting’s, pg. 700

55
Q

_________ mL of sodium citrate can be given ________ minutes before induction to decrease gastric fluid pH

A
  • 15-30
  • 15-30

Stoelting’s, pg. 700

56
Q

What are the possible complications of antacid therapy?

A
  • bacterial overgrowth of duodenum
  • UTI
  • acid rebound

Stoelting’s, pg. 700
Dr. C’s powerpoint

57
Q

List 2 drugs that are histamine type 2 receptor antagonists

A
  • Cimetidine
  • Famotidine

Stoelting’s, pg. 703

58
Q

Describe the mechanism of action of cimetidine/famotidine

A
  • They are both H2 receptor antagonists
  • Blockade of H2 receptors reduces the secretion of H+ ions in the stomach by parietal cells

there is also some reduction of gastric fluid volume

Stoelting’s, pg. 703-704

59
Q

Increasing age must be considered when determining the dose of H2-receptor antagonists - cimetidine clearance may decrease by ___________% in patients between the ages of 20 and 70 years

A
  • 75%

bolded on Dr. C’s slides

Stoelting’s, pg. 705

60
Q

True or false:

The ASA has recommended that all patients routinely receive H2RA to decrease the risks associated with pulmonary aspiration

A
  • False - routine use in patients who have no apparent increased risk for pulmonary aspiration is not recommended

Stoelting’s, pg. 705

61
Q

What are the most common adverse side effects associated with H2RAs?

A
  • diarrhea
  • headache
  • fatigue
  • skeletal muscle pain

see also table 35-3

Stoelting’s, pg. 706

62
Q

____________ are the most effective drugs available for controlling gastric acidity and volume

A
  • proton pump inhibitors

bolded on Dr. C’s slides

Stoelting’s, pg. 709

63
Q

How long before surgery should omeprazole be administered to ensure adequate chemoprophylaxis/increase in gastric pH?

A
  • > 3 hours

onset of antisecretory effect ~2-6 hours

Stoelting’s, pg. 710

64
Q

Name several side effects related to the PPIs

A
  • headache
  • abdominal pain
  • agitation/confusion

Stoelting’s, pg. 710

65
Q

What class of medication is aprepitant (Emend)? Describe its mechanism of action

A
  • substance P/Neurokinin 1 (NK-1) receptor antagonist
  • NK-1 receptors, located in the nucleus of the solitary tract (NST), are involved in central regulation of GI tract
  • GI vagal afferents and other input converge in the NST to initiate emesis

NST located within the medulla

Nagelhout, pg. 211

66
Q

What kind of patient will you not give Metoclopramide?

A
  • Suspected or known mechanical bowel obstruction
  • After GI surgery or intestinal anastomosis

Nurs 575 Anesthesia Pharmacology (9 decks)

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