Exam 4

Fentanyl brand

Abstral, Duragesic, Fentora

Fentanyl class

Opioid analgesic

Fentanyl use

Pain

Fentanyl MOA

Opioid agonist at the mu receptor

Fentanyl dose

IV: 50-100 mcg loading dose with 25-50 mcg/hr titrated to patient need, transdermal patch: 25-100 mcg/hr

Fentanyl contraindications

Do not use in opioid naive patients

Fentanyl BBW

Life threatening respiratory depression, addiction, misuse, abuse, risk of concomitant use with benzodiazepines or other CNS depressants

Dexmedetomidine brand

Precedex

Dexmedetomidine class

Sedative

Dexmedetomidine use

Sedation

Dexmedetomidine MOA

Selective alpha 2 adrenergic agonist, inhibits norepinephrine release, peripheral alpha 2b-adrenoceptors

Dexmedetomidine dose

ICU sedation: 1 mcg/kg IV over 10 minutes followed by 0.2-0.7 mcg/kg/hr maintenance, procedural sedation: 1 mcg/kg IV over 10 minutes with 0.6 mcg/kg/hr maintenance

Dexmedetomidine contraindications

None

Dexmedetomidine BBW

None

Ketamine brand

Ketalar

Ketamine class

General anesthetic

Ketamine use

Anesthesia

Ketamine MOA

Noncompetitive NMDA receptor antagonist that blocks glutamate

Ketamine dose

IM: 4-10 mg/kg, IV: 0.5-2 mg/kg

Ketamine contraindications

None

Ketamine BBW

None

Lidocaine brand

Lidoderm, Xylocaine

Lidocaine class

Analgesic anesthetic

Lidocaine use

Anesthesia

Lidocaine MOA

Local antiarrhythmic class IB

Lidocaine dose

Topical 4.5 mg/kg/day divided in 4 doses or apply 5% patch to painful area for 12 hours every day

Lidocaine contraindications

Use with caution in patients with known drug sensitivities

Lidocaine BBW

Fatal events have occured with high blood levels from topical exposure and is more likely in young children

Midazolam brand

Nayzilam, Versed

Midazolam class

Benzodiazepine

Midazolam use

Sedation, agitation, end of life, seizures

Midazolam MOA

Binds to stereospecific benzodiazepine receptors on the postsynaptic GABA neuron, essentially enhances the inhibitory effects of GABA on neuronal excitability. Impact on GABA-A and not GABA-B receptors

Midazolam dose

Preop sedation: 0.1-0.35 mg/kg over 20-30 seconds, seizures: 5 mg nasal spray as a single dose in one nostril; may repeat dose in 10 minutes in alternate nostril based on response and tolerability

Midazolam contraindications

None

Midazolam BBW

Has been associated with respiratory depression and respiratory arrest, especially when used for sedation in noncritical settings

Naloxone brand

Evzio, Narcan

Naloxone class

Opioid antagonist

Naloxone use

Opioid overdose

Naloxone MOA

Pure opioid antagonist that competes and displaces opioid at receptor sites

Naloxone dose

IV/IM/SQ: initial 0.4-2 mg repeated q2-3 min up to 10 mg total, intranasal: 1 spray (4 mg) as a single dose in one nostril, may repeat in 3-5 min if respiratory depression persists

Naloxone contraindications

None

Naloxone BBW

None

Propofol brand

Diprivan

Propofol class

General anesthetic

Propofol use

Anesthesia, RSI

Propofol MOA

Short acting lipophilic IV general anesthetic, results in CNS depression through GABA-A agonism and glutamatergic activity through NMDA receptor blockade

Propofol dose

Initial IV: 5 mcg/kg/min (or 0.3 mg/kg/hr) increase by 5-10 mcg/kg/min (or 0.3-0.6 mg/kg/hr) every 5-10 min until desired sedation level is achieved, maintenance: 5-50 mcg/kg/min (0.3-3 mg/kg/hr)

Propofol Contraindications

Hypersensitivity to eggs, soybeans, soy production, caution with hypertriglyceridemia

Propofol BBW

None

What is this?

Tetrodotoxin, a sodium channel neurotoxin that comes from pufferfish and greater blue ring octopus

What is this?

Saxitoxin, a sodium channel neurotoxin that comes from dinoflagellates

What is the primary MOA for neurotoxins?

Block the sodium channel from the outside in its ionized form

What is the primary MOA for alcohols, phenols, and benzocaine?

Block sodium channel from within the membrane in its unionized form

What is the primary MOA for local anesthetics?

Block sodium channel from the inside, most efficient MOA

What is this?

Cocaine

What is this?

Benzocaine

What is this?

Benzonatate

What is this?

Procaine

What are some SAR features of benzoic acid esters?

Aromatic ring, para EDG, ester better than amid, 2-4 carbon chain, usually tertiary basic amine

What does coadministration of a benzoic acid ester with a vasoconstrictor prevent?

Degradation by esterases, diffusion away from injection site

How is this metabolized?

Rapid ester hydrolysis

What is this?

Lidocaine

What is the general MOA of inhalation general anesthetics?

Membrane fluidization

How is the action of barbiturates terminated?

Drugs redistributing to fat

What is rapid sequence intubation?

Airway management technique for quickly securing an airway

What are indications for intubation?

Respiratory failure, apnea, GCS < 8, rapid change of mental status, airway injury, high risk for aspiration, trauma to larynx

What is the pharmacist’s role in intubation?

Assist with medication and dose selection, obtaining meds, drawing up meds at appropriate dose, recommend treatments for medication side effects

When might we use premedications for RSI?

Patient appears anxious, hypotensive, hypertensive

What does the induction agent do?

Sedate patient prior to procedure

What does the paralytic agent do?

Paralyzes the muscles to reduce risk of injury with intubation

What are possible complications of RSI?

Bradycardia, hypotension

Why do we give premedications in RSI?

Help with anxiety and blunt any negative physiological response that occurs during intubation such as a spike in BP or pain

When would we use midazolam in RSI?

Premedication for anxiety

Midazolam MOA

GABA agonist, fast acting BZP with short duration of action

What is the usual dose of midazolam?

1-2 mg IV push

Fentanyl MOA (RSI)

Central opioid agonist that blunts the sympathetic surge associated with pain receptor stimulation

Why is fentanyl a preferred opioid for RSI?

High degree of lipophilicity with fast onset and short duration of action

Fentanyl dose

1-3 mcg/kg IV 3 minutes prior to intubation

Which patients would benefit from the addition of fentanyl as a premedication?

Cardiac issues such as ischemic heart disease and aortic dissection

When do we use atropine in RSI?

Premedication more common in pediatric patients for bradycardia

Atropine MOA

Muscarinic antagonist

Why might a patient become bradycardic during intubation?

Vagus nerve activation

Lidocaine MOA

Suppresses reflexes, induces peripheral GABA receptors, brain stem depression, slows cerebral metabolism

When do we use lidocaine for RSI?

Premedication to blunt sympathetic response to intubation in patients with elevated ICP or have asthma with bronchospasm

What are adverse effects of lidocaine?

Hypotension, arrythmias

Why do we sedate the patient prior to administering the paralytic agent?

Don’t want tehm to remember the experience, overall better patient care

Propofol MOA

Highly soluble GABA agonist

What about propofol makes its kinetics optimal for induction?

Fast onset, short duration of action, highly lipophilic, no renal/hepatic considerations

What effects does propofol have minus sedation?

Reduces ICP, bronchodilation, hypotension, bradycardia

Can propofol be used in patients with an egg allergy since it’s a lipid emulsion?

Yes

Etomidate MOA

Stimulates GABA to block neuroexcitation and induce sedation and unconsciousness

What cardiovascular effects does etomidate have?

Very minimal, won’t negatively impact one way or the other

What is the dose of etomidate?

0.2-0.6 mg/kg, generally eyeballed though

Ketamine MOA

Inhibits glutamate at NMDA receptor, highly lipophilic so crossed BBB easily, provides analgesia and amnesia

What cardiovascular effects does ketamine have?

Hypertension, tachycardia, increased CO, induces bronchodilation

When is midazolam a good option as an induction agent?

No IV access

Which induction agent is generally our first option and why?

Etomidate, neutral cardiac profile

How do depolarizing NMBAs work?

Bind to Ach receptors leading to membrane depolarization and keeps it open so muscles cannot contract and relax

How do non depolarizing NMBAs work?

Competitively block Ach receptors but do not activate them

Why is paralysis with a NMBA indicated prior to intubation?

Keep the patient from moving around for their safety