Week 6: Antiemetics, Prokinetics, Antihistamines, Serotonins Flashcards
1
Q
Along with pain , ____ is the most important complaint patients report following surgery under anesthesia
A
PONV
2
Q
______ is the leading cause of unanticipated hospital admission following outpatient surgery
A
PONV
3
Q
Without prophylaxis, nausea occurs in up to ____% of patients who receive ______________
Can be as high as ____% in high risk patients
A
40%
general anesthesia
80%
4
Q
A patient that experiences nausea or who vomits within ____ hours of a surgical procedure that required anesthesia meets the criteria for the diagnosis of PONV
Early PONV within ___ hours
Later PONV ___ -___ hours after procedure
A
24
6
6-24
(even if they’re discharged, if it falls within 24 hours anesthesia is to blame)
5
Q
PONV is a major patient _______ issue
A
satisfaction
6
Q
PONV can be associated with morbidity due to: (5)
A
Dehydration
Electrolyte abnormalities
Wound dehiscence (f/ wretching)
Bleeding
Esophageal rupture
Airway compromise
7
Q
Patients with nausea have a ________ feeling of the need to vomit
A
subjective
8
Q
Emesis may or may not be preceded by _______
A
nausea
9
Q
Sequence of events that occur during emesis are controlled by the _____ ______, which lies in the ________ ________
A
vomiting center
medulla oblongata
10
Q
A NUMBER OF ____________ MODULATE THE ACTIVITY OF THE VOMITING CENTER
A
Neurotransmitters
(can have multimodal PONV management = trying to hit as many different receptors as we can)
11
Q
______ and ______ of neurotransmitters in the vomiting center are used to prevent nausea and vomiting
A
Agonist and antagonists
12
Q
Slightly cephalad to the vomiting center is the ________ ______ ___
A
Chemoreceptor trigger zone
13
Q
The chemoreceptor trigger zone detects ______ chemicals in the bloodstream
A
noxious
14
Q
6 influences on the vomiting center
A
Dopamine
Serotonin
Substance P
Acetylcholine
y-Aminobutyric acid (GABA)
Cannabinoids
15
Q
______ agents used for the prevention and treatment of nausea and vomiting
A
Antiemetic
16
Q
In order to determine whether prophylaxis is indicated, it is important to assess patient’s _____ _____
A
risk factors
17
Q
Patient factors which increase risk of PONV: (4)
A
Women
Nonsmokers
History of motion sickness
Previous episodes of PONV
18
Q
Surgical factors which increase risk of PONV
A
Plastic surgery
Orthopedic surgery
Gynecologic surgery
Breast surgery
ENT surgery
Long surgical procedures
Laparoscopic surgery
19
Q
Anesthetic factors which increase risk of PONV
A
Use of inhalation anesthetic, and
nitrous
Neostigmine
Opioids
20
Q
_______ approach for prophylaxis and rescue therapy in patients that develop PONV works well due to the complexity of the systems involved in the pathogenesis of PONV
A
Multimodal
(try to use different agents that work on different receptors = highest chance of success in preventing PONV)
21
Q
Scopolamine class
A
Anticholinergic
22
Q
Scopolamine
Prevention of ______ -_______ nausea and vomiting
A
motion induced
23
Q
Scopolamine
1 patch in place ___ -____ hours
A
24-72 hours
24
Q
Scopolamine is generally well tolerated without prohibitive side effects such as ______, ______ (paralysis of the ciliary muscle of the eye), or ______ of secretions
A
sedation, cycloplegia, drying
25
Scopolamine
Don't touch eyes without washing hands = _____ ______
Pupil dilation
26
Metoclopramide drug class
Benzamide
27
Metoclopramide is a _____ antiemetic that stimulates the gastrointenstinal tract via _______ mechanisms that result in increased _____ and ____ ______ mobility
WEAK
anticholinergic
gastric, small intestine
(not a great antiemetic, usually given for prokinetic effects, not a routine agents for prevention of PONV
28
Metoclopramide has ___________ activity, and should be used with caution in all patients with: (3)
Antidopaminergic
Restless leg syndrome
Parkinson's disease
Movement disorders related to
dopamine inhibition or depletion
29
__________, a feeling of unease and restlessness in lower extremities, can occur following IV administration of metoclopramide
Sometimes so severe it can result in ________ of surgery, may manifest in PACU
Akathisia
cancellation
30
Midazolam class
Benzodiazepine
(not a "go to" agent for PONV, can slow wakeup)
31
Midazolam
If used for antiemetic effects, should be administered IV towards ____ of surgical procedure or by _______ infusion in intubated or ventilated patients in the ICU
end
continuous
32
Midazolam MOA for PONV
Believed to decrease ________ emetic effect, and decreases the release of _______
dopamine's
serotonin
33
Droperidol and haloperidol class
Butyrophenones
34
US FDA put black box warning restrictions on droperidol due to _______ _____ ______ sometimes seen with higher doses than are necessary for treatment of PONV
prolonged QT interval
35
Droperidol considered effective at low doses of _____ - ______ IV
0.625-1.25 mg
36
Haloperidol effective at low doses of ____ - ____ mg IV
0.5-2 mg
37
Droperidol and haloperidol
_________ symptoms are a risk, and drugs should be used cautiously in patients with __________, _________, and ____________
Extrapyramidal
Restless leg syndrome
Parkinson's disease
Movement disorders related to
dopamine inhibition or depletion
38
Droperidol is as effective as _______ or __________ in preventing and treating PONV
dexamethasone
ondansetron
39
Droperidol and haloperidol have sedating effects, so give _______ to minimize prolonged sedation
up front
40
Barhemsys (Amisulpride) class
Butyrophenones
41
Barhemsys (Amisulpride)
Selective ___ and ___ receptor _____
D2 and D3 receptor antagonist
42
Barhemsys (Amisulpride)
Approved as a ______ agent for PONV
rescue
43
Barhemsys (Amisulpride)
Recommended dosage ___ - ____mg IV
5-10
44
Barhemsys (Amisulpride)
Avoid in patients with congenital _____ ____ _______
long QT syndrome
45
Barhemsys (Amisulpride)
Advertised as sedating or non-sedating?
Non-sedating
46
Dexamethasone class
Corticosteroid
47
Dexamethasone has similar efficacy to ________ and __________
ondansetron and droperidol
48
Dexamethasone dose is ___ - ____ mg
4-8mg
49
Dexamethasone
______ side effect profile with single dose administration
Minimal
50
Dexamethasone
_______ and ______ patients at increased risk for perioperative hyperglycemia with single dose
Obese and diabetic
51
ONDANSETRON, tropisetron, granisetron, dolasetron class
5-HT3 receptor antagonists
52
ONDANSETRON, tropisetron, granisetron, dolasetron class
_____ specific and evoke _____ side effects
Highly, minimal
53
Ondansetron ___mg, dexamethasone ____mg, and droperidol ____mg administered before induction of general anesthesia are equally effective in decreasing the incidence of PONV
4mg
4mg
1.25mg
(give 30 mins before induction; varying sources)
54
Ondansetron is effective when administered ____ or ____
PO or IV
55
Ondansetron and other 5HT3 antagonists can cause slight ________ _____ ______ on ECG
prolongation of the QTc interval
56
Dimenhydrinate (Dramamine) class
Histamine receptor antagonist
57
Dimenhydrinate (Dramamine) effective in prevention of _____ as well as __________
PONV, motion sickness
58
Administration of Dimenhydrinate (Dramamine) ____mg IV in adults decreases vomiting after outpatient surgery
20mg
59
In children Dimenhydrinate (Dramamine) ____mg/kg IV significantly decreases incidence of vomiting after ________ surgery
0.5mg/kg
strabismus
60
EMEND, akynzeo, varubi class
Neurokinin 1 receptor antagonists (P/NK-1) receptor antagonists
61
Neurokinin receptors are found in the ______________ (____), where they are involved in the central regulation of ______ function
nucleus of the solitary tract (NST)
visceral
62
Neurokinin 1 receptor antagonists are believed to provide antiemetic activity by suppressing activity in the _______, where vagal afferents from the ____ ______ converge with inputs from the area _______ and other regions of the brain that initiate emesis
nucleus of the solitary tract (NST)
GI tract
postrema
63
Dose of Emend is ____mg PO
40mg PO
64
Aspiration during general anesthesia occurs in approximately 1 in ______ adults and 1 in _______ children
1 in 8500
1 in 4400
65
Increased risk for aspiration (2)
Emergency operations
Bowel obstruction
66
Factors associated with pulmonary complications of aspiration include the _____ and _____ of the aspirated gastric contents
volume and acidity
67
Drugs that ____ the pH of gastric contents (______) and that _____ the volume of gastric contents (_______) have a role in decreasing the severity of the sequelae of aspirating gastric contents
increase (antacids)
decrease (prokinetic drugs)
68
Enforcement of the American Society of Anesthesiologist Task Force Fasting Recommendations can also reduce the risk of _______ _____
pulmonary aspiration
69
Antacids are drugs that _________ (remove hydrogen ions) acid from the gastric contents or decrease secretion of ________ ________ into the stomach
neutralize
hydrogen chloride
70
Occasional failure of particulate antacids to increase gastric fluid pH may reflect ____________ or __________
inadequate mixing with stomach contents
an unusually large volume of gastric fluid
71
Pneumonitis associated with functional and histologic changes in the lungs may reflect a ______ ______ ________ to inhaled particulate antacid particles
foreign body reaction
72
________ (______) antacids are less likely to cause a foreign body reaction if aspirated
and their mixing with gastric fluid is _____ _______ than is that of particulate antacids
(SODIUM CITRATE)
Nonparticulate (clear)
more complete
73
The onset of effect is more rapid with ______ ______ than with particulate antacids that require a longer time for adequate mixing with gastric fluid
sodium citrate
74
SODIUM CITRATE, ____ to ____ mL ADMINISTERED ____ to ____ mins BEFORE INDUCTION OF ANESTHESIA , if effective in reliably increasing gastric fluid pH in pregnant and nonpregnant patients
15 to 30 mL
15 to 30 mins
(very common in OB patients, C-sections)
75
Complications of Antacid therapy (8)
Hypophosphatemia (osteomalacia,
osteoporosis)
Urinary tract infections
Milk-alkali syndrome
(hypercalcemia, systemic
alkalosis)
Bacterial overgrowth in small
intestine
Acid rebound (unique to calcium
containing antacids)
Drug interactions
Urolithiasis (chronic administration)
Altered renal elimination of drugs
(d/t increased urinary pH)
76
Complications of antacid therapy;
Drug interacions
Speed delivery and absorption of:
-salicylates
-indomethacin (NSAID)
-naproxen
Decreased availability of:
-Cimetidine (antacid, antihistamine)
77
Histamine induces _______ of smooth muscles in the _______
contraction
airways
78
Histamine _________ the secretion of acid in the stomach
increases
79
Histamine stimulates the release of ___________ in the CNS
Neurotransmitters
80
Histamine receptor antagonists bind to receptors on _____ ____ ______, to the exclusion of agonist molecules, without themselves activating the receptor (histamine receptor antagonists do not inhibit release of histamine)
effector cell membranes
81
H1-receptors antagonists are characterized by _____-generation and ____-generation receptor antagonists
First-generation
Second-generation
82
_______ -GENERATION DRUGS TEND TO PRODUCE SEDATION, whereas ____-generation drugs are relatively nonsedating
FIRST
Second
83
The selectivity of the _____ -generation antagonists for H1 receptors decreases ____ toxicity
Second
CNS
84
H1 receptor antagonists are well absorbed after oral administration, often reaching peak plasma concentrations within ___ hours
2
85
H1 receptor antagonists prevent and relieve the symptoms of allergic rhinoconjunctivitis: (5)
-Sneezing
-Nasal and ocular itching
-Rhinorrhea
-Tearing
-Conjunctival erythema
86
H1 receptor antagonists are less effective for the nasal congestion characteristic of a _______ allergic reaction
delayed
87
First-generation H1-receptor antagonists have sedating effects that result in _______ reaction times
delayed
88
Diphenhydramine is prescribed as a _______, an _______, and an _______-
sedative, antipruritic, antiemetic
89
Diphenhydramine
In combination with systemic or neuraxial opioids to control nausea and pruritis, there is the conceptual risk of __________ of ventilation
depression
90
Antihistamines are used in the acute treatment of ________ reactions
anaphylactic
91
The administration of ________ plus the administration of ________ is indicated in the treatment of acute anaphylaxis
H1-receptor antagonist, epinephrine
92
H1-receptor antagonists may be administered prophylactically for __________ reactions to ___________
anaphylactoid, radiocontrast dye
93
First-generation H1- receptor antagonists often have adverse effects on the CNS, including (4)
Diminished alertness
Impairment of cognitive function
Slowed reaction time
Somnolence
94
H1-receptor antagonists
Cardiac effects
________ is common, and ___________, _________, and ________ have occurred
Tachycardia, heart block, prolongation of QTc interval, cardiac arrhyhthmias
95
Second-generation H1-receptor antagonists are unlikely to produce ______ side effects
CNS
96
H2-receptor antagonists produce ______ and _______ inhibition of H2 receptor-mediated secretion of ____ ____ by parietal cells
selective, reversible
hydrogen ions
97
Cimetidine, Ranitidine, FAMOTIDINE, Nizatidine class
H2-receptor antagonist
98
The absorption of cimetidine and famotidine is ______ after oral administration
rapid
99
Due do extensive __________, however, the bioavailability of H2-receptor antagonists is approximately 50%
first-pass hepatic metabolism
100
Does hepatic dysfunction seem to significantly alter pharmacokinetics of H2-receptors antagonists?
No
101
CIMETIDINE CLEARANCE DECREASES ____% BETWEEN THE AGES OF ____ YEARS AND ____ YEARS
75%
20 and 70 years
102
H2 receptor antagonists have no influence on the pH of gastric fluid that is ________
already present in the stomach
(only affect what's coming down the line; need oral antacid for what's already in the stomach)
103
Patients with allergic histories or patients undergoing procedures associated with increased likelihood of allergic reactions (contrast dye) may include _______ oral administration of an H1-receptor antagonist
Diphenhydramine ___ to ___mg/kg and an H2 receptor antagonist cimetidine ___mg/kg every ___ hours in the 12 to 24 hours preceding the possible triggering event
A _____ administered at least 24 hours earlier is commonly added to this regimen
Prophylactic
0.5 to 1.0mg/kg
4mg/kg
6 hours
corticosteroid
104
Side effects of H2 receptor antagonists
Interaction with cerebral H2 receptors (HA, somnolence, confusion)
Interaction with cardiac H2 receptors (bradycardia, hypotension, heart block)
Increased hepatic transaminases
Interstitial nephritis
Interfere with drug metabolism by cytochrome P450
Hyperprolactinemia
Acute pancreatitis
Thrombocytopenia
Alcohol dehydrogenase dehydration
Agranulocytosis
105
PROTON PUMP INHIBITORS ARE THE MOST EFFECTIVE DRUGS AVAILABLE FOR CONTROLLING _______ AND ______
Gastric acidity and volume
106
Omeprazole provides prolonged inhibition of ___________, regardless of stimulus
gastric acid secretion
107
Omeprazole inhibits ______, _____, and ______ acid secretion to a significantly greater degree than the _____________
daytime, nocturnal, and meal-stimulated
H2-receptor antagonists
108
Omeprazole heals ________ and possibly _______ ulcers more rapidly than the ____________
duodenal, gastric
H2-receptor antagonists
109
Omeprazole effectively ______ gastric fluid pH and _______ gastric fluid volume in children and adults
increases, decreases
110
Onset of the gastric antisecretory effect of omeprazole after a single 20mg oral dose occurs within ____ to ____ hours
2 to 6 hours
111
Oral omeprazole should be administered > ___ hours before anticipated induction of anesthesia to ensure adequate chemoprophylaxis
3
112
Motility-modulating drugs exert their therapeutic effects by increasing ____________ tone, enhancing ________ ________, and accelerating the rate of _______ ________
lower esophageal sphincter
peristaltic contractions
gastric emptying
113
Metoclopramide is a _________ blocker, acts as a gastrointestinal _______ drug
dopaminergic
prokinetic
114
Metoclopramide increases ___________ tone and stimulates motility of the ______ _______ _______ in normal persons and parturients
lower esophageal sphincter
upper gastrointestinal tract
115
_________ is the only drug approved by the U.S. Food and Drug Administration for the treatment of diabetic gastroparesis
Metoclopramide
116
Metoclopramide ___________ gastric clearance of liquids and solids and ______ transit time through the small intestine
accelerates
shortens
117
Metoclopramide is ______ absorbed after oral administration
rapidly
118
Metoclopramide reaches peak plasma concentrations in ___ to ___ minutes
40 to 120
119
Metoclopramide has extensive __________ metabolism that limits its bioavailability to ____%
first-pass hepatic
75%
120
Metoclopramide, ___ to ___ mg IV over __ to __ mins administered ____ to ____ minutes before induction of anesthesia, results in increased lower esophageal sphincter tone and decreased gastric fluid volume
10 to 20mg
3 to 5 mins
15 to 30 mins
121
The gastric emptying effect of metoclopramide may be of potential benefit before the induction of anesthesia in: (5)
Trauma patients
Obese patients
Patients who have recently ingested
solid food
Patients with DM and symptoms of
gastroparesis
Parturients, especially those with
a hx of esophagitis "heartburn'
122
Metoclopramide should be avoided in patients with ___________, __________, ___________
Restless leg syndrome
Parkinson's disease
Movement disorders related to
dopamine inhibition or depletion
123
___________, a feeling of unease and restlessness in the lower extremities, may follow the IV administration of metoclopramide
Akathisia
124
IV administration of metoclopramide may be associated with: (4)
Hypotension
Tachycardia
Bradycardia
Cardiac arrythmias
125
DO NOT ADMINISTER METOCLOPRAMIDE TO A PATIENT WITH A SUSPECTED OR KNOWN _________ _________ TO GASTRIC EMPTYING
mechanical obstruction
126
Do not administer metoclopramide after gastrointestinal surgery including _______ or ________ _________ due to its stimulation of gastric motility which may delay healing
pyloroplasty
intestinal anastomosis
127
metoclopramide has an inhibitory effect on _______ ______________ activity
plasma cholinesterase
128
metoclopramide's inhibitory effect on plasma cholinesterase activity may explain occasional observations of prolonged responses to ___________
succinylcholine
129
The metabolism of _____ _____ _______ could be slowed by metoclopramide-induced decreases in plasma cholinesterase activity
ester local anesthetics
