General Anesthetics & Sex Hormones

Front 1

Inhaled General Anesthetics

Back 1

1. Nitrous Oxide
2. Isoflurane
3. Enflurane
4. Desflurane
5. Sevoflurane

Front 2

IV General Anesthetics

Back 2

1. Propofol
2. Etomidate
3. Ketamine

Front 3

General Anesthetic Adjuncts

Back 3

1. Midazolam
2. Fentanyl
3. Dexmedetomidine

Front 4

3 requirements to achieve an anesthetic state

Back 4

1. Amnesia
2. Immobility in response to noxious stimulation
3. Attenuation of autonomic response to noxious stimulus

Front 5

Balance Anesthesia

Back 5

the use of multiple classes of drugs to achieve the desired depth of anesthesia

Front 6

GA used to induce anesthesia because they are faster acting

Back 6

IV GAs

Front 7

GAs used for maintenance of anesthesia

Back 7

Inhaled GAs

Front 8

Emergence Excitement

Back 8

condition where the half conscious patient exhibits restlessness, crying, moaning, and in extreme cases thrashing

Front 9

Only inhaled GA that is a gas

Back 9

Nitrous oxide

Front 10

Pharmacokinetics of inhaled general Anesthetics

Back 10

1. effect of gas is proportional to concentration in CNS
2. faster the effects wear off post-surgery, faster they start to recover

Front 11

High water (Blood) solubility for Inhaled GAs

Back 11

slow induction = long time to fully dissolve in blood

Front 12

Low water (Blood) solubility for inhaled GAs

Back 12

rapid induction = not soluble in blod and rapidly enters CNS

Front 13

Blood/Gas Partition Coefficient

Back 13

measure of water solubility

GA in blood / GA in lung

Front 14

Minimum Alveolar Concentration (MAC)

Back 14

*concentration of inhaled GA needed for 50% of patients to not respond to pain*

proportional to lipid solubility (greater the lipid solubility, greater the potency)

Front 15

Summary of Inhaled GA

Back 15

1. speed of induction inversely related to H2O solubility while potency is proportional to lipid solubility

Front 16

Mechanism of Action of Inhaled General Anesthetics

Back 16

alter cell membranes and enhance inhibitory membrane-bound receptors(GABA) or inhibit excitatory membrane-bound receptors (NMDA)

Front 17

Nitrous Oxide

Back 17

1. low water and lipid solubility = fast acting and not very potent
2. weak anesthetic
3. colorless, odorless gas
4. S/E: air pockets(earaches), change BP

Front 18

Enflurane

Back 18

1. Sweet odor
2. slightly less potent than Halothane
3. no need to worry about liver damage
4. S/E: produces electrical seizure activity

Front 19

Common Side Effects of most General Anesthetics

Back 19

1. decrease in blood pressure, peripheral dilation
2. decrease ventilation rate
3. muscle relaxation

Front 20

Isoflurane

Back 20

1. pungent odor
2. almost all is eliminated unchanged via the lungs
3. S/E: mild tachycardia, modest vasodilation in cerebral vasculature
4. preferred GA for neurosurgery

Front 21

Desflurane

Back 21

1. irritating gas - coughing, respiratory, secretions, must use IV GA to induce anesthesia
2. fast induction and recovery
3. most is eliminated unchanged via the lungs

Front 22

Sevoflurane

Back 22

1. Reacts with dried out soda lime (CO2 absorber) - heat, airway burns also form Compound A (renal damage)
2. used alone is non-irritating
3. most is eliminated unchanged via lungs
4. fast induction and recovery
5. no change in Cardiac Output and preferred for patients prone to Myocardial Ischemia

Front 23

Propofol

Back 23

1. duration: 4-8 minutes
2. not water soluble - very fatty - used with caution on patients with high TGs
3. most common induction agent in US

Front 24

Mechanism of Action of Propofol

Back 24

enhance effects of GABA at GABAa inhibitor receptors

Front 25

Side effects of Propofol

Back 25

1. major decrease in BP, vasodilation, and myocardial contractility
2. pain of injection
3. anti-emetic properties
4. does not cross placenta - safe for pregnancy

Front 26

Etomidate

Back 26

1. duration: 4-8 minutes
2. not water soluble
3. used for patients at risk for hypotension
4. induction and maintenance of anesthesia

Front 27

Mechanism of Action of Etomidate

Back 27

enhance effects of GABA at GABAa inhibitor receptor and activate GABAa receptor without GABA present

Front 28

Side effects of Etomidate

Back 28

1. pain of injection
2. myoclonic movements (use benzos)
3. nausea and vomiting
4. no decrease in BP or cardiac output

Front 29

Ketamine

Back 29

1. duration: 10-15 minutes
2. water soluble (IV, oral, rectal, IM)
3. produces profound analgesia (no need for fentanyl)

Front 30

Mechanism of Action of Ketamine

Back 30

1. competitive antagonist of NMDA receptor and inhibition of voltage sensitive Na, K channels

Front 31

Side Effects of Ketamine

Back 31

1. emergence delirium (1 hour post emergence)
2. hallucinations, vivid dreams, illusions (Benzos help)
3. Ventilation - only modest decrease in ventilation rate and is potent bronchodilator
4. CV - increase BP, increase Cardiac Output, Increase heart rate

Front 32

how do GA adjuncts help

Back 32

decrease the dose of GA needed to reach desired depth of anesthesia

Front 33

Midazolam

Back 33

*Benzodiazepines*

1. produce anesthesia - only at high doses
2. Used for pre-op sedation (also amnesia)
3. water soluble
4. no pain on injection
5. more rapid onset (2 mins)

Front 34

Fentanyl

Back 34

*Opioids*

1. potent analgesic
2. given at induction for later intubation, initial incision
3. minimize vascular reflex to noxious, painful stimuli
4. duration: 30 minutesDexmedetomidine

Front 35

Mechanism of Action of Fentanyl

Back 35

mu opioid receptor agonist

Front 36

Dexmedetomidine

Back 36

1. alpha 2 adrenergic agonist - good for long term care (ICU)
2. approved for strong sedation
3. IV use only and no amnesia
4. S/E: decrease in BP, bradycardia, no change in ventilation rate
5. USE: non-intubated patients

Front 37

Hypothermia

Back 37

1. core body temp is below 36 degrees C
2. common in prolonged procedures due to body cavities being exposed
3. GAs cause vasodilation which greatly facilitate body heat loss

Front 38

Malignant Hyperthermia

Back 38

adverse reaction to inhaled GAs that is associated with a very high morality rate if untreated

Core body temp rapidly increases to over 42 degrees C as a result of uncontrolled muscle rigidity

Front 39

Mechanism of Malignant Hyperthermia

Back 39

1. Ryanodine calcium channels do not close resulting in uncontrolled muscle contraction leading to heat generation
2. Fatigued myocytes lyse releasing potassium = fatal cardiac events

Front 40

Treatment of Malignant Hyperthermia

Back 40

Dantrolene - ryanodine receptor inhibitor

Also treats spasms and spastic disorders

Front 41

Estrogens in OCs

Back 41

Ethinyl Estradiol

Front 42

Progestins in OCs

Back 42

1. Levonorgestrel
2. Desogestrel
3. Drospirenone
4. Etonogestrel
5. Norgestimate
6. Norgestrel
7. Norethindrone
8. Medroxyprogesterone

Front 43

Topical - Transdermal Oral Contraceptive

Back 43

Ortho Evra

Front 44

Vaginal Ring for OC

Back 44

Nuvaring

Front 45

Progestin only contraceptives

Back 45

1. Micronor; Nor-Q.D.
2. Depo-Provera
3. Dep-subq Provera 104
4. Implanon implanted under skin

Front 46

Intrauterine devices

Back 46

1. Paraguard
2. Mirena

Front 47

Emergency Contraceptives

Back 47

1. Plan B
2. Ella
3. Next Choice

Front 48

Phases of the Menstrual Cycle

Back 48

1. Follicular Phase
2. Ovulatory Phase
3. Luteal Phase
4. Fertilization and Implantation

Front 49

Monophasic B/C

Back 49

fixed dose of estrogen and progestin during the cycle

Front 50

Multiphasic B/C

Back 50

*biphasic, triphasic, four-phasic*

regimen better mimics the normal hormonal events during the menstrual cycle

Front 51

Biphasic B/C

Back 51

estrogen remains constant and the progestin dose changes twice

Front 52

Triphasic

Back 52

dose of one or both steroidal agents are changed 3 times

Front 53

Four-Phasic

Back 53

*Natazia*

1. total of 4 different steroidal agent combinations
2. estrogen changes dose 3 times during hte cycle

Front 54

Estrogens undergo what process

Back 54

*Enterohepatic Recirculation*

1. sulfate and glucuronide conjugation
2. biliary secretion
3. cleaved by bacterial enzymes - allow reabsorption

ALLOWS TO MAINTAIN LEVELS

Front 55

Physiological Effects of Estrogen

Back 55

1. play role in development of reproductive parts
2. promote proliferation of endometrium
3. important roe in ovulation and menstrual cycle
4. maintenance of blood vessels and skin structure
5. decrease bone resorption

Front 56

Physiological Effects of Progesterone

Back 56

inhibits the estrogen-induced proliferation of the endometrium and converts the endometrium to a secretory tissue....produces a thick cervical mucous

Front 57

Mechanism of Action of Combination oral Contraceptives

Back 57

utilize physiologic negative feedback mechanisms at the level of the hypothalamus and anterior pituitary to INHIBIT THE RELEASE OF ANTERIOR PITUITARY GONADOTROPINS WHICH INHIBITS OVULATION

Front 58

Major SIDE EFFECTS of Oral Contraceptives

Back 58

Thromboembolic Disorders - risk is ~3x great

Estrogen - increases the serum concentrations of clotting factors and decreasing antithrombin III

Front 59

Health care providers should educate patients using oral contraceptives about what?

Back 59

1. A - abdominal pain (severe)
2. C - chest pain (severe)
3. H - Headaches (severe)
4. E - eye problems (blurred vision, flashing lights, blind)
5. S - severe leg pain (calf or thigh)

Front 60

ADRs of oral contraceptives

Back 60

1. Nausea - most frequent
2. brownish pigmentation of skin, acne, hirsutism
3. HTN, MI (increased in women over 35yrs old)
4. Thromboembolic disorder
5. decrease glucose tolerance
6. overall increase in plasma TG and LDL
7. Breakthrough bleeding (spotting)
8. CNS and Ocular problems
9 Cancer (breast, cervical)

Front 61

Beneficial Effects with combination oral contraceptives

Back 61

1. decreased cancer incidence (endometrial, ovarian)
2. Acne vulgaris

Front 62

Drug-Drug Interactions with combination oral contraceptives

Back 62

1. Antibiotics
2. Anticonvulsants

Front 63

Absolute contraindications for use of combination oral contraceptives

Back 63

1. thromboembolic disease
2. MI
3. coronary artery disease
4. hyperlipidemia
5. women over 35yrs old who smoke heavily

Front 64

Relative contraindications for use of combination oral contraceptives

Back 64

1. migraine headaches
2. HTN
3. diabetes

Front 65

Ortho Evra

Back 65

*TOPICAL - TRANSDERMAL SYSTEM*

1. placed on abdomen, buttocks, upper torso or upper arm
2. start on 1st day of menses or replaced every week for 3 weeks
**leads to adverse side effects such as thromboembolism**

Front 66

NuvaRing

Back 66

*Vaginal Ring*

1. inserted prior to 5th day of menstrual cycle and stays inserted for 3 weeks
2. usually discontinued due to accidental expelling or sensation of foreign body

Front 67

Micronor; Nor-Q.D.

Back 67

*Progestin Only Prep*

1. used in women who have contraindications for the use of estrogen-containing contraceptives or are lactating and want contraception
2. ADRs: menstrual irregularities and weight gain

Front 68

Depo Provera

Back 68

*Progestin Only Prep*

1. IM injection every 3 months - inhibits ovulation
2. injection should occur within 5 days of beginning of menstrual bleeding
3. ADRs: osteoporosis, menstrual irregularities, weight gain

Front 69

Depo-SubQ Provera 104

Back 69

*Progestin Only Prep*

1. SubQ injection - self administration
2. very expensive

Front 70

Implanon

Back 70

*Progestin Only Prep*

1. rod containing etonogestrel placed under the skin and releases drug over time
2. Rod removed at or before the end of the third year

Front 71

Paraguard

Back 71

*Intrauterine device*

1. copper
2. left in place ~10 years
3. prevents fertilization, implantation, interfere w/ sperm transport

Front 72

Mirena

Back 72

*Intrauterine Device*

1. Levonorgestrel
2. left in place ~5 years
3. production of thick cervical mucous

Front 73

ADRs of Paraguard and Mirena

Back 73

1. low grade inflammation
2. insertion of these devices may introduce bateria into the genital tract

Front 74

Plan B kit

Back 74

*Emergency Contraception*

1. 1 tablet taken within 120 hours after intercourse

Front 75

Next Choice

Back 75

*Emergency Contraception*

1. 2 tablets taken within 120 hours after intercourse

Front 76

Mechanism of Action of Plan B, Next Choice, Ella (Unipristal)

Back 76

inhibits or delays ovulation, decreases endometrial receptivity, decreases activity of the corpus luteum, production of cervical mucous

Front 77

Major Adverse Effects of the Emergency Contraceptives

Back 77

1. Nausea and vomiting - can be alleviated by prescribing an antiemetic

Front 78

Estrogen Pills - oral

Back 78

Premarin

Front 79

Estrogen and Progestin monophasic pills

Back 79

Prempro

Front 80

Other ways to receive ERT or HRT

Back 80

1. vaginal administration
2. transdermal preps

Front 81

Selective Estrogen Receptor Modulators (SERMS) and Anti-estrogens

Back 81

1. Raloxifene Hcl (Evista)
2. Clomiphene

Front 82

GnRH agonist

Back 82

Leuprolide acetate

Front 83

Gonadotropins

Back 83

1. menotropins (Pergonal)
2. recombinant FSH preps - Follitropin alpha and beta
3. chorionic gonadotropin (Pregnyl)
4. recombinant hCG - choriogonadotropin alfa (Ovidrel)

Front 84

Topical Testosterone

Back 84

Androderm

Front 85

5 alpha reductase inhibitors

Back 85

1. finasteride (proscar, propecia)
2. dutasteride (avodart)

Front 86

Signs and Symptoms of Menopause

Back 86

1. hot flashes, night sweats
2. sleep disturbances
3. vaginal dryness
4. mood changes

Front 87

Dosing regimens for HRT

Back 87

1. continuous-cyclic or sequential therapy
2. continuous-combined therapy

Front 88

When can ERT and HRT be used

Back 88

1. vasomotor symptoms
2. Vaginal dryness

Front 89

Treatment of Vasomotor symptoms

Back 89

1. Estrogen is most effective
2. symptoms usually disappear ~1-2 years
3. Replacement therapy can be stopped after ~2-3 years

Front 90

Treatment of Vaginal dryness

Back 90

1. estrogen containing creams, tabs, or vaginal ring

Front 91

When ERT and HRT should not be used

Back 91

1. Prevent Osteoporosis
2. Prevent Cardiovascular disease
3. Alzheimers disease

Front 92

Adverse Effects of postmenopausal hormone thearpy

Back 92

1. Breast Cancer
2. Breast Tenderness
3. Nausea
4. Thromboembolism - ~2fold risk in first couple years

Front 93

"Bioidentical" hormone therapy

Back 93

a fad pseudo drug therapy for estrogen replacement treatment (Suzanne Summers)

Front 94

Raloxifene HCl

Back 94

MOA: estrogen agonist in bone -exerts anti-resportive effect *not associated w/ endometrial proliferation or increased risk of breast cancer

USES: prevent osteoporosis (inc total BMD 1.3-2%) and breast cancer

ADRs: vasomotor symptoms (hot flashes), thromboembolism

CONT: venous thrombosis, not used during prolonged immobilization

Front 95

Clomiphene Citrate

Back 95

MOA: potent anti-estrogenic activity & weak estrogenic activity AND inhibits negative feedback of estrogen (PROMOTES RELEASE OF FSH and LH)

USE: Female infertility - induces ovulation

ADRS: hot flashes, multiple ovulations, cyst formation, visual problems, ovarian cancer

Front 96

Leuprolide

Back 96

MOA: GnRH agonist

USE: prostate cancer (palliative treatment)

ADRs: *well tolerated* hot flashes and night sweats

Front 97

Menotropins

Back 97

MOA: consists of LH and FSH given IM

USES: males - stimulate spermatogenisis AND females - induce ovulation in infertile women

ADRs: ovarian enlargement, abdominal distension, pain

Front 98

Follitropin alpha and Follitropin beta

Back 98

MOA: recombinant FSH preps administered subq

Front 99

Chorionic gonadotropin (Pregnyl)

Back 99

*administered by IM injection*

USES: prepubertal cryptochidism, spermatogenesis, ovulation induction

ADRs: ovarian hyperstimulation and multiple pregnancy

Front 100

Androderm

Back 100

*testosterone delivery*

USES: male hypogonadism or testosterone deficiency, male senescence, athletic enhancement

Front 101

Finasteride (Proscar, Propecia)

Back 101

MOA: competitive inhibitor of the type II 5a reductase enzyme

USE: decrease prostate size and increase urine flow rate, male pattern baldness

Front 102

Dutasteride (Avodart)

Back 102

MOA: competitive inhibitor of both the Type I and Type II 5a reductase enzyme

USE: decrease prostate size and increase urine flow rate