Drugs (s/e, dosing, MOA, onset, peak, etc) & some cardiac

Question 1

Trade name for Succinylcholine?

Answer 1

Anectine

Question 2

Trade name for Mivacurium?

Answer 2

Mivacron

Question 3

Trade name for Atracurium?

Answer 3

Tracurium

Question 4

Trade name for Cisatracurium?

Answer 4

Nimbex

Question 5

Trade name for Vecuronium?

Answer 5

Norcuron

Question 6

Trade name for Rocuronium?

Answer 6

Zemuron

Question 7

Trade name for d-Tubocurarine?

Answer 7

Tubarine

Question 8

Trade name for Pancuronium?

Answer 8

Pavulon

Question 9

Name the following (ultrashort, short, intermediate, or long):

1) Succinylcholine
2) Pancuronium
3) Mivacurium
4) Cisatracurium
5) d-Tubocurarine
6) Rocuronium
7) Atracurium
8) Vecuronium

Answer 9

1) Succinylcholine: ultra short
2) Pancuronium: long
3) Mivacurium: short
4) Cisatracurium: intermediate
5) d-Tubocurarine: long
6) Rocuronium: intermediate
7) Atracurium: intermediate
8) Vecuronium: intermediate

Question 10

Name the onset time for the following:

1) Succinylcholine: ultra short
2) Pancuronium: long
3) Mivacurium: short
4) Cisatracurium: intermediate
5) d-Tubocurarine: long
6) Rocuronium: intermediate
7) Atracurium: intermediate
8) Vecuronium: intermediate

Answer 10

1) Succinylcholine: 0.5-1.5 min
2) Pancuronium: 2-4 min
3) Mivacurium: 3-4 min
4) Cisatracurium: 5-7 min
5) d-Tubocurarine: 2-4 min
6) Rocuronium: 1-1.5 min
7) Atracurium: 3-4 min
8) Vecuronium: 3-4 min

Question 11

Name the duration to 25 % recovery for the following:

1) Succinylcholine: ultra short
2) Pancuronium: long
3) Mivacurium: short
4) Cisatracurium: intermediate
5) d-Tubocurarine: long
6) Rocuronium: intermediate
7) Atracurium: intermediate
8) Vecuronium: intermediate

Answer 11

1) Succinylcholine: 6-8 min
2) Pancuronium: 60-120 min
3) Mivacurium: 15-20 min
4) Cisatracurium: 35-45 min
5) d-Tubocurarine: 60-120 min
6) Rocuronium: 30-40 min
7) Atracurium: 35-45 min
8) Vecuronium: 35-45 min

Question 12

Name the ED95 for the following:

1) Succinylcholine: ultra short
2) Pancuronium: long
3) Mivacurium: short
4) Cisatracurium: intermediate
5) d-Tubocurarine: long
6) Rocuronium: intermediate
7) Atracurium: intermediate
8) Vecuronium: intermediate

Answer 12

1) Succinylcholine: 0.30 mg/kg
2) Pancuronium: 0.06 mg/kg
3) Mivacurium: 0.08 mg/kg
4) Cisatracurium: 0.05 mg/kg
5) d-Tubocurarine: 0.50 mg/kg
6) Rocuronium: 0.30 mg/kg
7) Atracurium: 0.20 mg/kg
8) Vecuronium: 0.05 mg/kg

Question 13

Name the primary route of elimination of the following:

1) Succinylcholine
2) Pancuronium
3) Mivacurium
4) Cisatracurium
5) d-Tubocurarine
6) Rocuronium
7) Atracurium
8) Vecuronium

Answer 13

1) Succinylcholine: metabolism (plasma cholinesterases)
2) Pancuronium: 85% RENAL/ 15% BILIARY
3) Mivacurium: metabolism
4) Cisatracurium: metabolism (HOFFMAN ONLY)–> nonspecific esterases are NOT involved
5) d-Tubocurarine: primary renal, secondary biliary
6) Rocuronium: 80% Biliary/ 20% renal
7) Atracurium: metabolism (2/3 by hydrolysis–> nonspecific esrterases, 1/3 by Hoffman elimination)
8) Vecuronium: 60% BILIARY/ 40% RENAL/ some metabolism
* *the termination of atracurium, cisatricurium, vec, and roc is by redistribution

Question 14

Place the following NMB’s into the appropriate category:
vec, roc, pancuronium, atracurium, cisatracurium
1) monoquaternary aminosteroids
2) bisquaternary aminosteroids
3) bisquaternary benzylisoquinolines

Answer 14

1) monoquaternary aminosteroids: vec, roc
2) bisquaternary aminosteroids: panc
3) bisquaternary benzylisoquinolines: atrac, cisatra
* *aminosteroids= “curonium”
* *benzylisoquinolines= “curium”
* *ALL are quaternary ammonium compounds

Question 15

Which NMB’s produce autonomic ganglionic blockade? (2)

Answer 15

d-tubocurarine and metocurine block nicotinic receptors at the autonomic ganglia

Question 16

Which NMB’s elicit the release of histamine? (5)

Answer 16

sux, mivacurium, atracurium, d-tubocurarine, and metocurarine

Question 17

Which NMB’s produce bradycardia and why? (1)

Answer 17

succinylcholine mimics the action of acetylcholine and directly stimulates muscarinic receptors of the sinoatrial node

Question 18

Which NMB’s produce tachycardia and why? (5)

Answer 18

• atracurium, d-tubocurarine, metocurine produce reflex tachycardia
• pancuronium and gallamine competitively antagonize acetylcholine, which are referred to as direct vagolytic, or more specifically antimuscarinic, actions

Question 19

Which NMB’s produce significant hypotension? (3)

Answer 19

succinylcholine, d-tubocurarine, metocurarine

Question 20

Which NMB’s produce significant hypertension? (2)

Answer 20

pancuronium and gallamine

Question 21

The acronym “M-SAC” is my way to remember NMB’s that are primarily eliminated by METABOLISM. What does it stand for?

Answer 21

M- mivacurium
S- succinylcholine
** BOTH of the above are by plasma cholinesterase
A- atracurium
2/3 hydrolysis, 1/3 Hoffman
C- cisatricurium
ALL by Hoffman

Question 22

I am a long acting non-selective alpha adrenergic antagonist used to control blood pressure in patients with pheochromocytoma.

Answer 22

phenoxybenzamine

* another non-selective alpha adrenergic antagonist is phentolamine

Question 23

I am a selective alpha 2 adrenergic antagonist used to treat impotence.

Answer 23

yohimbine

Question 24

How is prazosin different from other alpha adrenergic antagonists?

Answer 24

unlike non-selective alpha blockers, prazosin (a selective alpha 1 adrenergic antagonist) lowers BP without increasing release of NE from postganglionic sympathetic nerve terminals b/c it doesn’t block alpha 2

Question 25

Name one of the primary non-selective beta antagonists, and why it isn't usually used for with irritable airways.

Answer 25

propanolol--> beta 2 adrenergic receptor blockade can induce bronchoconstriction

Question 26

I am a competitive antagonist of beta 1 adrenergic receptors. I am also very short acting and am metabolized in the _______ by __________ of the red blood cell.

Answer 26

Esmolol. in the plasma by non-selective esterases of the red blood cells

Question 27

What are some uses of esmolol?

Answer 27

1) treat intraop SVT 2) treat intraop HTN 3) blunt reflex cardiovascular responses to DL and produce controlled hypotension

Question 28

What receptors does labetalol competitively antagonize?

Answer 28

alpha 1, beta 1, beta 2

Question 29

Name 2 uses of labetalol?

Answer 29

1) treat HTN emergencies 2) produce controlled hypotension * decreases HR, myocardial contractility, and SVR

Question 30

What is the alpha to beta ratio of the block produced by labetalol?

Answer 30

7:1 beta to alpha (so stronger beta than alpha)

Question 31

What drugs can be used to treat excess myocardial depression induced by beta antagonists?

Answer 31

1) Atropine (incremental doses of 7mcg/kg) 2) Dobutamine (selective beta 1) 3) Calcium Chloride (250 to 1000mg IV) 4) Glucagon (1-10 mg IV, followed by 5 mg/hr IV) 5) transvenous artificial cardiac pacer * Isoproterenol not good d\t its beta 1 and beta 2 effects, could cause vasodilation * Dopamine NOT recommended

Question 32

Why is Ketamine not normally recommended for use with beta blockers?

Answer 32

b\c it promotes SNS stimulation and with beta blockade it promotes increased SVR--> not able to be compensated by increased myocardial contractility (b\c the heart is beta blocked)--> heart failure may ensue *same thing can happen with pheochromocytoma if beta blockade is produced prior to alpha blockade

Question 33

What alpha adrenergic blocker could you use to control HTN during a pheo case?

Answer 33

phentolamine (regitine)

Question 34

What drugs should you avoid in the asthmatic patient?

Answer 34

1) beta 2 blockers like propanolol and labetalol | 2) drugs that stimulate histamine release (trimethaphan, d-tubocurarine, atracurium, and mivacurium)

Question 35

Order MOST to LEAST on sedation: atropine, scopolamine, robinul.

Answer 35

scopolamine, atropine, glyco

Question 36

Order MOST to LEAST on antisialogogue: atropine, scopolamine, robinul.

Answer 36

scopolamine, glyco, atropine

Question 37

Order MOST to LEAST on increased HR: atropine, scopolamine, robinul.

Answer 37

atropine, glyco, scop

Question 38

Order MOST to LEAST on relax smooth muscle: atropine, scopolamine, robinul.

Answer 38

atropine and glyco, scop

Question 39

Order MOST to LEAST on mydriasis: atropine, scopolamine, robinul.

Answer 39

scop, atropine, glyco

Question 40

Order MOST to LEAST on motion sickness prevention: atropine, scopolamine, robinul.

Answer 40

scopolamine, atropine, glyco

Question 41

What antimuscarinic LEAST crosses the BBB?

Answer 41

glyco, b\c it has a charged quaternary ammonium group (ions DO NOT like to cross lipid membranes)

Question 42

What is the treatment for anticholinergic syndrome?

Answer 42

physostigmine (an acetylcholinesterase inhibitor) 15-60mcg/kg IV

Question 43

T/F? Decreased tone of the lower esophageal sphincter is a disadvantageous feature of antimuscarinics.

Answer 43

TRUE

Question 44

What is the action of milrinone?

Answer 44

well... cAMP is normally cleaned up by phosphodiesterase...... so, milrinone is a PDA blocker--> causing a buildup of cAMP

Question 45

When administering terbutaline... what receptor does it agonize? Is it metabotropic or ionotropic? Why?

Answer 45

works on beta 2--> terbutaline is a 1st messenger (Gs protein)--> the substrate ATP combines with enzyme adenylyl cyclase to activate 2nd messenger cAMP (the product)--> activates protein kinase--> bronchodilation

Question 46

When looking at bronchiole smooth muscle, the presence of Ca+ indicates _______.

Answer 46

constricition.... absence of Ca+ = dilation

Question 47

How does nitric oxide (NO) work?

Answer 47

it is a 1st messenger that crosses the lipid membrane (lipid soluble, so no receptor needed)--> acts with GTP--> cGMP (2nd messenger inside the cell)--> bronchodilation

Question 48

What is the 2nd messenger of terbutaline in bronchiole smooth muscle?

Answer 48

cAMP

Question 49

What is the 2nd messenger of nitric oxide in bronchiole smooth muscle?

Answer 49

cGMP

Question 50

What is the 2nd messenger of atropine and ipratroprium in bronchiole smooth muscle?

Answer 50

IP3 and Ca+; AcH binds to muscarinic receptor--> phospholipase C cuts the head off... that is IP3--> IP3 helps release Ca+--> both are second messengers--> bronchoconstriction

Question 51

cAMP and cGMP are "cleaned up" by _________.

Answer 51

phosphodiesterase; but different kind called isoform

Question 52

Name the phosphodiesterase isoform for: cAMP

Answer 52

PDE III

Question 53

Name the phosphodiesterase isoform for: cGMP

Answer 53

PDE V

Question 54

What is aminophylline?

Answer 54

a phosphodiesterase inhibitor--> so causes buildup of cAMP--> promote bronchodilation as cAMP accumulates

Question 55

How does nitroglycerin and nitroprusside (nitric oxide donors) promote bronchodilation?

Answer 55

by increasing the concentration of cGMP

Question 56

How do atropine and ipratropium (atrovent-- an inhaled antimuscarinic) promote bronchodilation?

Answer 56

competitively inhibit muscarinic 3 receptors

Question 57

What 4 second messengers are at work in bronchial smooth muscle cells?

Answer 57

1) cAMP 2) cGMP 3) IP3 4) Ca+

Question 58

In bronchial smooth muscle, which first messenger does NOT bing to a cell membrane receptor?

Answer 58

nitric oxide (NO)

Question 59

Name two common xanthines.

Answer 59

aminophylline and theophylline--> competitively antagonize adenosine receptors CNS: nervousness, anxiety, n/v RESP: bronchodilation

Question 60

Does aminophylline readily cross the placenta?

Answer 60

YES

Question 61

How do antimuscarinics cause bronchodilation?

Answer 61

atropine & ipratropium (atrovent); they antagonize AcH--> cause bronchodilation because less inositol triphosphate IP3 is produced, so less calcium is available for contractile proteins

Question 62

What second messenger promotes bronchoconstriction?

Answer 62

Ca+ and IP3

Question 63

Anti HTN: Name the trade name and action: hydralazine

Answer 63

Apresoline--> arterial vasodilator

Question 64

Anti HTN: Name the trade name and action: diazoxide

Answer 64

Hyperstat--> arterial dilator (can cause hypoglycemic coma)

Question 65

Anti HTN: Name the trade name and action: nitroglycerin

Answer 65

venodilator

Question 66

Anti HTN: Name the trade name and action: nitroprusside

Answer 66

Nipride--> arterial and venous dilator

Question 67

CCB: Name the trade name and action: verapamil

Answer 67

Calan, Isoptin--> arterial dilator and decreased HR

Question 68

CCB: Name the trade name and action: diltiazem

Answer 68

arterial dilator and decreased HR

Question 69

CCB: Name the trade name and action: nifedipine

Answer 69

Procardia--> arterial dilator (causes reflex increase in HR)

Question 70

ACE INH: Name the trade name and action: captopril

Answer 70

Capoten--> arterial dilator

Question 71

ACE INH: Name the trade name and action: enalapril

Answer 71

Vasotec--> arterial dilator

Question 72

PDE INH: Name the trade name and action: inamrinone

Answer 72

Inocor--> block breakdown of cAMP= inc. myocardial contractility= dec. SVR (relaxes vascular smooth muscle)

Question 73

PDE INH: Name the trade name and action: milrinone

Answer 73

Primacor--> block breakdown of cAMP= inc. myocardial contractility= dec. SVR (relaxes vascular smooth muscle)

Question 74

What is the action of Adenosine?

Answer 74

it is an endogenous nucleotide occurring in all cells of the body.... can be administered to: 1) slow conduction of impulses through the AV node 2) interrupt reentry pathways through AV node 3) restore NSR in pt's with paroxysmal SVT, including the associated WPW syndrome

Question 75

What is the dose of Adenosine?

Answer 75

6-12 mg IV as rapid injection

Question 76

What is the elimination half time of Adenosine?

Answer 76

< 10 seconds owing to rapid metabolism

Question 77

"Fast, Full, and Forward" applies to ______.

Answer 77

regurgitation; you want a faster HR so you spend LESS time in systole

Question 78

What is the mneumonic to remember what will increase or decrease an outflow obstruction?

Answer 78

Old Cats Pee Alot Obstruction: up down (increased or decreased) ------------------------------------------- Contractility: up down Preload: down up Afterload: down up

Question 79

Is ephedrine good to give a patient with a valve obstruction?

Answer 79

No! increases HR (you want to maintain)

Question 80

Is digitalis good to give a patient with a valve obstruction?

Answer 80

No! increases contractility and worsens obstruction

Question 81

Is increasing PEEP good for a patient with a valve obstruction?

Answer 81

No! decreases venous return= Not good, worsens obstruction

Question 82

Aortic regurgitation can either be congenital or from ______.

Answer 82

rheumatic fever--> causes valvular problems

Question 83

Aortic annulus dilation can cause regurgitation. What are causes of aortic annulus dilation?

Answer 83

syphilis, rheumatoid and psoriatic arthritis, ankylosing spondylitis, cystic medial necrosis, annuloaortic ectasia

Question 84

What happens when there is aortic regurgitation and eccentric LV hypertrophy?

Answer 84

ventricles experience a large increase in volume with a small increase in pressure... left ventricular compliance is large--> fluid backs up into LV and starts to dilate it

Question 85

Where is the coronary "take-off" located?

Answer 85

right after the aortic arch

Question 86

Patients with acute aortic regurgitation present with the sudden onset of _______ and _______.

Answer 86

``` pulmonary edema and HTN typically the 3 things seen are: 1) severe dyspnea 2) hypotension 3) weakness ```

Question 87

Chronic aortic regurgitation normally presents as _______. Symptoms are minimal when the regurgitant volume are < _____, and severe if > ______ of SV.

Answer 87

CHF; 60% Can remembers rule of 1/2's: 1/2 SV= severe

Question 88

Chronic aortic regurgitation can be heard as a ______ murmur, best heard at the _______.

Answer 88

diastolic murmur, best heard at the left sternal border (b\c blood is flowing anterograde * other manifestations: widened pulse pressure, bounding peripheral pulses, mitral regurg

Question 89

Arterial waveform of a pt with IHSS may be ____.

Answer 89

bifid.... bisferiens pulse

Question 90

What is the pressor of choice with aortic and mitral regurgitation?

Answer 90

Ephedrine... keep it fast full and forward.. phenylephrine would increase the afterload

Question 91

Chronic mitral regurgitation is usually d\t _______. (3)

Answer 91

rheumatic fever, incompetent valve, or destruction of mitral valve annulus

Question 92

What is the rule to remember when comparing the symptomatic progression of mitral regurgitation?

Answer 92

rule of 1/3rds | 60= severe

Question 93

Chronic mitral regurgitation is heard as a ________ murmur, best heard at the _____.

Answer 93

holosystolic murmur best heard at the apex