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210 Cards in this Set

  • Front
  • Back
Which muscle relaxant is excreted the most renally?
Pancuronium

What is the hallmark of propofol infusion syndrome?

Metabolic acidosis + Cardiac dysfunction + rhabdomyolysis + other stuff

How is atracurium metabolized and excreted?
Hoffman degradation and ester hydrolysis by nonspecific esterases
How is vecuronium metabolized? (% urine, liber, bile)
15% urine, 25% liver, 60% bile
How is rocuronium metabolized? (% urine, liber, bile)
10% urine, 20% liver, 70% bile
Endocrine side effect of etomidate?
Blocks 11-beta-hydroxylase activity (adrenal suppression)
What receptors does labetalol block?
beta-1, beta-2, and alpha-1
How does ondansetron work?
5-HT3 receptor antagonist
At what receptors does metoclopramide work? (3)
D2 antagonist, 5HT-4 AGonist, weak 5HT-3 blocker
How does droperidol work?
D2 antagonist
Myasthenia gravis: how does it affect SCh?
More resistant
Why are patient's with myasthenia gravis more resistant to SCh?
SCh needs to activate an absolute number of receptors to work; less receptors available in MG

Myasthenia gravis: how does it affect ND-NMBA?

Need less ND-NMBA

Why are patient's with myasthenia gravis more sensitive to ND-NMBA?

Fewer receptors needed to be blocked by the ND-NMBA's to achieve good blockade

What is myasthenic syndrome?
Lambert-Eaton Syndrome: antibodies against pre-synaptic Ca channels
How does Huntington's chorea affect sensitivty to SCh?
More sensitive
Why are patient's with Huntington's chorea more sensitive to SCh?
Decreased pseudocholinesterases
SCh sensitivity in myasthenic syndrome (LES)?
Increased sensitivity (easier to block NMJ acitivity with less presynaptic calcium channels)
What else (other than muscle weakness) should you watch out for in myasthenic syndrome?
Autonomic dysfunction (orthostatic hypotension) and gastroparesis
ND-NMBA sensitivity in myasthenic syndrome (LES)?
Increased sensitivity (easier to block NMJ acitivity with less presynaptic calcium channels)
Which anesthestic's sedation mimics sleep?
Dexmedetomidine
Which drug is water-soluble in its bottle, but lipid soluble in blood?
Midazolam
Max dose of epinephrine for local injection?
5 mcg/kg
What is the concentration of 1:100,000 epinephrine?
1 gram per 100,000 mL = 1,000,000 mcg / 100,000 mL = 10 mcg/mL
What is the concentration of 1:200,000 epinephrine?
1 gram per 200,000 mL = 1,000,000 mcg / 200,000 mL = 5 mcg/mL
Why should you avoid beta-blockers in asthma?
Can precipitate bronchoconstriction (beta-2 agonist = albuterol)
How do anticholinergics affect LES tone?
Decreased (more relaxation = more vomiting risk)
How do inhalational agents affect LES tone?
Decreased (more relaxation = more vomiting risk)
How does propofol affect LES tone (at normal doses)?
No effect
How do opioids affect LES tone?
Decreased (more relaxation = more vomiting risk) except with propofol
How do NMBA's affect LES tone?
Increase!
Which anticholinesterase can cross the BBB?
Physostigmine (tertiary compound, unlike other quartenary compounds)

Which IV anesthestic blocks NMDA activity?

Ketamine

Which opioid agonist has anticholinergic properties as well?
Meperidine
How does ketamine affect ICP? Why?
Increased ICP; potent cerebral vasodilator
Ketamine stereoisomers? Which is more potent?
Sold as a racemic mixture; S-enantiomer is more potent
How does ketamine affect respiration?
No effect
Ketamine metabolite potency?
Norketamine; 20% potency
What are the indirect sympathetomimetic drugs? (4)
Ephedrine, amphetamines, mephentermine, metaraminol
Which sympathetomimetic drug is a beta-1 AND beta-2 agonist?
isoproterenol
Which sympathetomimetic drug is a beta-1 agonist only?
dobutamine
Which sympathetomimetic drug is an alpha-1 agonist only? (2)
phenylephrine (and methoxamine)
What receptors does epinephrine act on?
beta-1 and beta-2 > alpha
What receptors does norepinephrine act on?
alpha > beta-1; NO beta-2
What is the difference in receptor activity between epi and norepi?
Alpha: norepi > epi; Beta-1: similar; Beta-2: epi only (no norepi activity)
Why does methylnaltrexone only work peripherally?
Cannot cross BBB due to it's structure
How do -navir drugs affect anesthetics?
Block CYP3A4 > decreased midazolam metabolism (increased sensitivity to midazolam)

What receptor does Substance P act on?

Neurokinin-1 (NK1) receptor

What are the effects of neurokinin-1 antagonists (apepitant)?
Anxiolysis, antidepressant, antiemetic, but NO analgesia (weird because Substance P assoc. w/ pain)
Patient is being treated for MG: how does this affect SCh activity?
MG treatment = anticholinesterase > blocks pseudocholinesterase > prolonged SCh activity
1 twitch (TOF) = ? % height reduction of single twitch?
90
Which NMBA's cause histamine release?
SCh and atracurium
Which NMBA's stimulate autonomic ganglia and cardiac mACh receptors?
SCh (because it is similar to ACh)
How does rocuronium affect cardiovascular function?
Weakly blocks cardiac mACh receptors
Which NMBA's block mACh receptors on the heart?
rocuronium (weakly) and pancuronium (moderately)
What are the two pathways for norepinephrine metabolism?
MAOI (intracellular) and COMT (liver)
How is the action of norepinephrine terminated, by what %? (two pathways)
80% repuptake (some MAOI degradation) and 20% circulation (COMT degradation in liver)
What should you give with ketamine to decrease emergence delirium?
Midazolam 5 mins before induction
How does metoclopramide affect LES?
Increases LES tone, stimulates motility (overall, less vomiting potential)
How much does SCh increase [K] by?
0.5 mEq/L
How does calcium affect ND-NMBA activity?
Decreases it (more Ca to cause NMJ activity)
How do aminoglycosides affect ND-NMBA activity?
Enhance
How do local anesthestics affect ND-NMBA acitivity?
Enhance
How do volatile anesthestics affect ND-NMBA activity?
Enhance
How does magnesium affect ND-NMBA activity?
Enhance
What two main anesthesia drugs can interact with MAOI's?
Ephedrine and meperidine
SCh and MS?
Avoid; MS can cause muscle weakness and hyperkalemia with SCh
SCh and Guillan-Barre?
Avoid; GBS causes paralysis and SCh can cause hyperkalemia
SCh and MG: how is potassium release affected?
More SCh is needed in SCh, K release remains the same as normal
Which antibiotics do NOT affect NMBA?
erythromycin (macrolide), cephalosporins, tetracyclines, penicillins
Which antibiotics potentiate NMBA?
aminoglycosides, clindamycin, and fluoroquinolones
How does neomycin help in hepatic encephalopathy?
Kills ammonia-producing gut bacteria
How does flumazenil help in hepatic encephalopathy?
GABA receptors are activated in HE, flumazenil blocks them
Normal duration of SCh block? (mins)
5-10
Normal dibucaine number? (%)
80
Incidence of heterozygous atypical pseudocholinesterase?
1/500
Heterozygous atypical pseudocholinesterase: dibucaine number? (%)
60
Heterozygous atypical pseudocholinesterase: block duration? (mins)
20
Homozygous atypical pseudocholinesterase: dibucaine number? (%)
30
Homozygous atypical pseudocholinesterase: block duration? (mins)
>60
Homozygous atypical pseudocholinesterase: incidence?
1/3200
What isotype of pseudocholinesterase causes SHORTER SCh duration?
C5
Days to peak effect of SCh hyperkalemia in burns, trauma, stroke, etc.?
10-50
Duration of effect (months) of SCh hyperkalemia in burns, trauma, stroke, etc.?
6 months
Main side-effect of flumazenil?
Nausea/vomiting
What is the pharmacodynamic limitation of ketorolac?
Dose-ceiling effect with regard to analgesia (>10mg)

Ketorolac is contraindicated with what medications?

probenecid (decreased ketorolac clearance), and pentoxifylline (PDE inhibitor, used for claudication)

Do not give what induction agents with AIP?
Barbituates and etomidate
Do not give what pain meds with AIP?
Ketorolac and pentazocine (partial KOP agonist, complete MOP antagonist)
Why is codeine less effective with SSRIs? (what specific enzymes)
SSRI inhibits CYP2D6 activity, which normally converts inactive codeine to active morphine
What are oxycodone and hydrocodone converted to in the body?
Oxymorphone and hydromorphone (Dilaudid)
Intra-arterial injection of etomidate: what should you do?
Observe; no adverse intra-arterial effects
Why does fentanyl have faster onset than morphine?
Higher lipid solubility
Which opioid reaches steady state fastest after infusion is started?
Remifentail (1hr)
Patient received bleomycin in the past: anesthestic considerations?
Keep FiO2 at lowest possible because of lifelong risk of testicular cancer w/ bleomycin, esp w/ high FiO2
Advantage of rocuronium over other ND-NMBAs?
Rapid onset: 1.5-3 minutes (vs 3-7 mins)
Onset of rocuronium after RSI dose?
1-1.5 minutes
How does acute hyperkalemia affect SCh?
Hyperkalemia > hyperpolarization > Harder for SCh to depolarize > resistance
How does acute hyperkalemia affect ND-NMBA?
Hyperkalemia > hyperpolarization > Harder for muscle to depolarize > more sensitive to ND-NMBA
What surgeries have increased risk of recall?
cardiac, endoscopic airway, C-section and trauma
At what % of receptor blockade can reversal be achieved?
<50%
What are the two tests to check is muscle strength is back?
100Hz tetanus and 5-second head lift
Which dopamine blocker can treat WPW?
Droperidol
Why is verapamil dangerous in WPW?
Blocks nodal conduction > more accessory pathway conduction
Treatment of HD stable WPW?
vagal, IV adenosine, Class 1 or 2 antiarrhythmics; avoid nodal blockers
Half-life of pseudocholinesterase?
12 hours
How much decrease in pseudocholinesterase (e.g. liver failure) to prolong SCh? (%)
75
Potency of steroids? (hydrocortisone, prednisone, methylpred, beta, dexa)?
Hydro: 1, pred: 4, methylpred: 5, dex/beta: 25
What is recovery index?
Time to spontaneous recovery of twitch height from 25% to 75%
Which NMBA's recovery index is not affected by age?
Atracurium and cistracurium (because metabolism only dependent on pH and temp)
SCh has what effect on HR? Why?
Stimulates nicotinic receptors of NONDOMINANT autonomic system (PNS dominant in adults)
SCh has what effect on HR in children after first dose? Why?
Bradycardia; Kids = SNS dominant, so SCh stimulates non-dominant (PNS) leading to bradycardia
SCh has what effect on HR in adults after first dose? Why?
Tachycardia; Adults = PNS dominant, so SCh stimulates non-dominant (SNS) leading to tachycardia

SCh has what effect on HR after 2nd dose? Why?

Bradycardia! Usually, 2nd dose after DL, SCh stimulates cardiac muscarinic receptors

SCh induced bradycardia in children: mechanism? (2)

Stimulation of nodal mACh-R by SCh and stimulation on nACh-R of nondominant PNS

Which anesthesia drugs are metabolized by non-specific esterases? (3)
Esmolol (RBC esterase), Remifentanil, and Atracurium (cistra = Hoffman ONLY)
SCh is contraindicated in children: why?
Undiagnosed myopathies/dystrophies can lead to fatal hyperkalemia
NMBA's of different duration are given in serial: the block will behave like which? (1st/2nd)
Duration will be closer to whatever the first drug is because it occupies most of the receptor sites
How can you decrease emergence delirium with sevo?
Pretreat with fentanyl, ketamine, nalbuphine, clonidine, Precedex
What is the side effect of etomidate that patient's complain about the most?
PONV
Pancuronium: cardiovascular side effects? Mechanism?
increase CO, BP, HR. 1. vagolytic 2. norepi reuptake inhibitor 3. norepi release
Side effect of IV dantrolene for MH?
Muscle weakness (most common), nausea, diarrhea, blurry vision
Side effects of oral dantrolene for UMN lesions?
Rarely, hepatitis and pleural effusions
Metformin: why discontinue it 48 hours before surgery?
Risk of acidosis ONLY in patients with poor renal or hepatic function
How long does naltrexone (oral agent, sometimes used for alcoholism) last?
24 hours
Why is buprenorphine hard to reverse with naloxone?
Extremely high affinity for MOP (33x morphine) even though it's a partial agonist; relatively resistant to naloxone
Anesthetic with highest incidence of PONV?
Etomidate (vs. Propofol, midazolam might be protective)
Which vasodilator only acts on pulmonary arteries?
Nitric oxide
Which vessels does nitroglycerin IV primarily dilate?
Veins > arteries
Which vessels does nitroprusside primarily dilate?
All vessels (veins, systemic arteries, pulmonary arteries)
Which vasodilators only act on systemic arteries? (2)
Hydralazine and nicardipine

What vessels does PGE1 dilate?

pulmonary arterial and systemic arterial >> veins

Which vasodilators are the best venodilators? (2)
Nitroglycerin and nitroprusside
Which vasodilators act on pulmonary arteries?
Nitric oxide, nitroprusside, and PGE1
Action at the NMJ is terminated by what mechanism?
Diffusion away from NMJ (not metabolism or elimination)

Dexmedetomidine: MOA?

highly selective alpha-2 agonist (1:1,600 a1:a2)

Dexmedetomidine: onset and peak?
rapid <5 minutes onset, 15 minutes to peak
Dexmedetomidine: cardiovascular effects?
Decrease in HR (can be profound) and CO; BP initially rises (peripheral alpha stimulation), then levels off, then drops (15% in an hour)

Why does BP initially rise then fall with dexmedetomidine?

Initial rise due to peripheral alpha-2 stimulation, eventually (1 hr) BP falls due to central alpha-2 overriding

What is fospropofol?
Prodrug of propofol (no hyperlipidemia, burning, or infection risk!)
Effects of pre-op H2-blockers on anesthetics?
P450 inhibition = longer diazepam, lidocaine duration

Anesthetics with least reported allergic reactions? (2)

ketamine and benzodiazepines

Alfentanil: potency (compared to fentanyl)
Lower (<25%)
Alfentanil: duration (compared to fentanyl)
Much shorter

Alfentanil: onset (compared to fentanyl)

Fastest opioid

Alfentanil: metabolism
96% cleared by liver in 1h (no renal dependence)
Hyperkalemia with SCh after burns: onset?
48h
Hyperkalemia with SCh after burns: peak
7-10 days
Clonidine dose for post-op shivering?
75 mcg IV
Patient gets still chest after induction: cause and treatment?
Cause = opioids; Treatment = NMBA
Which induction agent causes the least respiratory depression?
Ketamine (2 mg/kg induction = 30-60s onset)
NMS possible treatment agents? (2)
Dantrolene and dopamine agonists (bromocriptine, amantadine)
How does cyanide toxicity work?
Binds Fe and inhibits cytochrome oxidase, inhibiting oxidative phosphorylation (cellular respiration)
Why is there no cyanosis in CN toxicity?
Oxygen is not used up because CN blocks cytochrome oxidase from binding oxygen
Treatment for CN toxicity?
Sodium thiosulfate (converts CN to thiocyanate); nitrites - generate metHb which binds CN
How does cyclophosphamide treatment affect anesthetic drugs?
Can decrease plasma cholinesterase
Lidocaine max dose for local anesthesia?
5 mg/kg or 300 mg
Lidocaine + epi max dose for local anesthesia?
7 mg/kg or 500 mg
Sugammadex dosing: emergency?
16 mg/kg
Sugammadex: normal dosing?
Deep (TOF = 0; PTC > 1) = 4 mg/kg; Moderate (TOF 2-4): 2 mg/kg
Sugammadex: contraindications?
Avoid in renal failure, not harmful but makes redosing NMBA tricky; kids < 18
What drugs can sugammadex bind and interfere with? (2)
Progesterone (OCP) and Toremifene (SERM for cancer)
How does chlorpromazine work?
D2 antagonist
How does chlorpromazine affect NMBA?
No effect
Milrinone: MOA?
PDE3 inhibitor > higher cAMP levels > positive inotrope + vasodilator
Milrinone: interaction with beta-blockers?
None (both increase cAMP via separate pathyways)
TCA: anesthetic considerations? mechanism?
TCA's decrease norepi reuptake: can exaggerate ephedrine's effects
Ephedrine effect in TCA user?
More pronounced because of higher norepi levels
MAC requirements in TCA users?
Higher MAC because of higher norepi and other neurotransmitters
Tirofiban: MOA?
Blocks GpIIb/IIIa (platelet receptor) interaction with vWF and fibrinogen
Clopidogrel: MOA?
Blocks ADP from binding P12Y2 receptor
What does P12Y2 activation by ADP do?
Conformational change in GpIIb/IIIa to bind ADP/fibrogen
What drugs inhibit GpIIb/IIIa?
abciximab, eptifibatide, tirofiban
How do heparin, LMWH and fondaparinux work?
Potentiate antithrombin III activity which inactivate factor Xa
What anesthetics are metabolized by non-specific esterases?
Remifentanil, esmolol, atracurium
Which IV drugs burn with injection?
Etomidate, Propofol and benzos that aren't midazolam (lorazepam and diazepam)
Irreversible alpha-blocker?
Phenoxybenzamine
Which drugs should you avoid in cardiac tamponade?
Negative inotropes (e.g. beta-blockers)
Why does dantrolene cause diuresis?
Formulated with mannitol
IV anesthetic that Adrenal suppression
Etomidate
IV anesthetic that Thrombosis, phlebitis, specific antagonist available
Lorazepam
IV anesthetic that Pain on injection, severe hypotension in elderly
Propofol
IV anesthetic that Increases ICP
Ketamine

IV anesthetic can cause lactic acidosis with prolonged use

Propofol

Which opioid is most likely to cause opioid-induced hyperalgesia?

Remifentanil

Opioids that demonstrates ceiling effect with regard to respiratory depression
Mixed agonist-antagonist drugs, such as butorphanol, nalbuphine, and pentazocine
Mixed agonist-antagonist drugs - butorphanol, nalbuphine, and pentazocine: MOA
partial KOP agonist, complete MOP antagonist
Opioid that causes antagonism of NMDA receptors
Methadone
Opioid that is also a norepinephrine reuptake inhibitor (NRI)
Tramadol and Tapentadol
Tramadol: MOA - inhibits? (6)
NMDA-R, serotonin and norepi reuptake, 5-HT2C-R, nACh, M1 and M3 mACh-R
Tramadol: MOA - agonist? (2)
partial μ-opioid, TRPV1-receptor
Yohimbe: MOA?
alpha-2 antagonist
Phase I block: fade?
Nope
Which block stage has posttetanic facilitation
Nondepolarizing and Phase II block
Effect on MAC: Amphetamines?
Acute: increased MAC; chronic: decreased MAC
Effect on MAC: alpha-2 agonists (clonidine)
Decrease
Effect on MAC: hyperthyroidism
No effect
Effect on MAC: Alcohol
Acute: decrease MAC; chronic: increased MAC
Effect on MAC: Lidocaine
Decrease
Effect on MAC: lithium
Decrease (lower catecholamine levels)
Effect on MAC: opioids
Decrease
Effect on MAC: duration of anesthesia
No effect
Effect on MAC: gender
No effect
Effect on MAC: Pregnancy
Decrease (sedative effects of progesterone)
Effect on MAC: severe hypoxia
Decrease
Which anticholinergics can cause CNS effects?
Tertiary: scopolamine and atropine
Least effective anticholinergic for decreased oral secretions?
Atropine
Effect of anti-ACh on LES tone?
Decrease
Which anticholinergic doesn't cross the BBB?
Glycopyrrolate
Which anticholinergics can cause mydriasis and cycloplegia?
Scopolamine (careful with rubbing eyes after patch) > atropine