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Alpha/Beta
| Question | Answer |
|---|---|
| Types of Sympathomimetics | Endogenous catecholamines, Synthetic catecholamines, Synthetic noncatecholamines |
| Vessel effects of the Sympathetic Nervous System | Vasoconstriction, Vasodilation (skeletal muscle) |
| Pulmonary effects of the Sympathetic Nervous System | Bronchodilation |
| Cardiac effects of the Sympathetic Nervous System | Chronotropy, increase HR/ Intotropy, contractility/ Dromotropy, SA node and AV node conduction |
| Adipose Tissue/Hepatic effects from Sympathetic Nervous System | Lipolysis, Glycogenolysis |
| What other things can be effected by the Sympathetic Nervous System | Insulin/Pituitary Hormone modulation |
| CNS effects of the Sympathetic Nervous System | CNS Stimulation |
| Sympathomimetic Amines mimic which part of the nervous system? | Sympathetic |
| What receptors are stimulated with with sympathomimetic amines? | Adrenergic |
| In general, sympathomimetics can be used to treat what problems? | Anaphylaxis, Shock, Heart Failure, Cardiac Resuscitation |
| Sympathomimetic Efficacy depends on... | Concentration at receptor site, Affinity for receptor, Population of receptors available for binding |
| What is another name for naturally occurring sympathomimetic amines? | Catecholamines |
| Examples of Catecholamines | Epinephrine, Norepinephrine, Dopamine |
| Ephedrine Class | Synthetic Noncatecholamine Sympathomimetic |
| Ephedrine Receptors | Alpha 1, Beta 1, Beta 2 |
| Ephedrine Mechanism of Action/Response | INDIRECTLY Stimulates release of endogenous Norepinephrine/ Increases HR/SBP/SVR |
| Ephedrine Dose/Onset/Duration of Action/Routes | 5-25mg IV Immediate 15 min. - 1.5 hrs. IV/PO/IM/SQ |
| Ephedrine Uses | Hypotension/Bronchoconstriction(PO), OB patients (no decrease in uterine perfusion) |
| Ephedrine Special Considerations | Resistant to MAO in the gut, Tachyphlaxis (Trauma/Sepsis/ICU pts.) |
| Phenylephrine Class | Synthetic Noncatecholamine Sympathomimetic |
| Phenylephrine Receptors | DIRECT Alpha 1 |
| Phenylephrine Mechanism of Action | Peripheral vasoconstriction |
| Phenylephrine Dose/Onset/Duration of Action/Routes | Bolus 50-200mcg Infusion 25-100mcg/min (start at 10) Immediate 5-20 min IV/Nasal |
| Phenylephrine Uses | Hypotension/SAH Pretreat for nasal intubation: Max dose 0.5mg (20mcg/kg in Peds) or **4 drops of 0.25%** |
| Phenylephrine Side Effect | Reflex Bradycardia (only those with intact Baroreceptors) |
| What patients benefit from Phenylephrine? | CAD, Aortic Stenosis (increases coronary perfusion without chronotropic effects) |
| Ephedrine Concentration | 50mg/1ml (Dilute in 9ml volume) |
| Phenylephrine Concentration | 10mg/1ml (Dilute 10mg in 100ml = 100mcg/ml) |
| Epinephrine Name | Adrenaline |
| Epinephrine Receptors | Alpha 1,2 Beta 1,2 |
| Epinephrine Uses | Anaphylaxis, CPR, Hypotension, Poor O2 tissue delivery |
| Epi Low Doses cause... | Vasodilation (Beta) |
| Epi High Doses cause... | Vasoconstriction (Alpha) |
| Epi Beta1 considerations | Increases myocardial O2 consumption and demand (Not good for CAD pts.), Dysrhythmias |
| Epi Beta 2 considerations | Bronchodilates - Stabilizes mast cells and decreases histamine release (Good for anaphylaxis), +RAAS, +Lipolysis, Gluconeogenesis, Glycogenolysis, Ketones, Hyperkalemia -Insulin |
| Epi Anaphylaxis Dose (Asthma) | 0.1-0.5mg (1:1000) SC/IM, 0.1-0.25mg (1:10000) IV over 5-10 min. (MAX 1mg) |
| Epi ACLS Dose | 1mg (1:10000) IV q 3-5 min |
| Norepinephrine Name | Noradrenaline (potent vasopressor) **SHOCK pts. |
| Norepi Receptors | Alpha 1, 2 Beta 1 |
| Main effects with Norepi | Increases SBP/DBP (increases Coronary perfusion), Increases SVR, may cause reflex bradycardia |
| Norepi Side Effect/Medication? | Extravasation/Dermal Sloughing Can add REGITINE (Phentolamine) 10mg/Liter to norepi drip to treat/prevent |
| Dopamine Uses | Systemic Shock, To increase UO |
| How is Dopamine metabolized? | MAO |
| Dopamine Low Doses | Dopaminergic: <2mcg/kg/min Increases renal blood flow, increases sodium excretion, inhibits aldosterone |
| Dopamine Medium Dose | Beta: 2-5mcg/kg/min Indirectly releases norepi, +Inotoropic effects |
| Dopamine High Dose | Alpha >10mcg/kg/min Vasocontriction (acts like epi, may switch to epi, dysrhythmias) |
| Dopamine Side Effects | IV infiltrate, Use Regitine (Phentolamine mesylate) - Alpha 1 blocker, 5-10mg/10ml, inject within 12 hours |
| Vasopressin Name | Arginine Vasopressin |
| Vasopressin Class | Antidiuretic Hormone |
| Where is Vasopressin formed and Secreted from? | Hypothalamus / Posterior Pituitary |
| Vasopressin target organs | Kidneys / Blood vessels |
| How does Vasopressin work on the kidneys? | V2 receptors increase water permeability on renal collecting tubules (via cAMP mechanism) |
| How does Vasopressin work on blood vessels? | V! binds to vascular smooth muscle and causes vasoconstriction (more on periphery than pulmonary muscles - good for those who have PULM HTN) |
| What mechanism does vasopressin use to effect blood vessels? | IP3 signal conduction pathway (release of Calcium from sarcoplasm) |
| Vasopressin indications | DI, Cardiac Arrest, Cardiogenic shock refractory to inotropes |
| Vasopressin Doses | DI: 5-10 U SC/IM BID-QID, Shock: 0.01-0.04U/min IV, Cardiac Arrest: 40 U IVP |
| Isopreterenol Class | Synthetic Sympathomimetic |
| Isopreterenol Receptors | Beta 1,2 |
| Isopreterenol Dose | 2-20mcg/min |
| Isopreterenol Uses | S. Brady unresponsive to Atropine, Status Asthmaticus, Post Heart Transplant (vagal dennervation) |
| Dobutamine Receptors | Weak Alpha, Strong Beta 1 |
| Dobutamine Uses | CHF |
| Dobutamine Side Effect | Hypotension in septic pts. due to decrease in SVR |
| What is another name for Phosphodiesterase inhibitors | Nonglycoside non catecholamine |
| Phosphodiesterase Inhibitor Mechanism of Action | Inhibit the breakdown for the enzyme Phosphodiesterase, which break down cAMP (more cAMP, more uptake of Calcium) |
| Phosphodiesterase Inhibitor examples | Milrinone / Amrinone |
| Which is preferred Milrinone/Amrinone? | Milrinone (Primacor) |
| Milrinone Considerations vs Amrinone | IV, easy to titrate, 15 more Inotropic potency than Amrinone (Inocor) |
| Amrinone Side Effects | PO: GI upset, thrombocytopenia Half life 2-4 hours (Kidneys eliminate) |
| What are some cardiac glycosides? | Calcium: Ca+ Chloride 10%/ Ca+ Gluconate 10%, Glucagon |
| Calcium Uses | +Inotropic, Hypocalcemia (after PRBCs), Hyperkalemia, Ca+CB/Beta blocker overdoes |
| Calcium Dose | 250-1000mg |
| Calcium Chloride 10% Concentration | 100mg/1ml (10ml = 1000mg) Provides 270mg Ca+ per gram (3x more than Ca+ gluconate 10%) |
| Calcium Gluconate 10% Concentration | Provides 90mg per Ca+ per gram (Less irritating to veins than Ca+ Chloride) |
| Glucagon Class | Calcium Glycoside |
| Where is glucagon produced? | Alpha cells of pancreas |
| What type of action does glucagon have? | +inotropic effects |
| What are some problems that glucagon can be used for? | Ca+CB/Beta blocker overdoes, relaxes Sphincter of Oddi |
| What are side effects of glucagon? | ST/Hyperglycemia |
| Alpha 2 agonist have what effects? | Inhibits SNS outflow, decreases MAC, Negative feedback which inhibits NE, Inhibits substance P. |
| What is substance P and where is it inhibited and by what? | Pain transmitter, its release is inhibited in the substangia geliatinosa of the spine (analgesia) by Alpha 2 agonist |
| What is the other name for Clonidine? What class of drug is it? | Catapres / Alpha 2 agonist |
| Where can Clonidine act? | Peripheral presynaptic Alpha 2 receptors - inhibits Catecholamines (vasodilation), Central postsynaptic Alpha 2 receptors - MAIN ACTION (decreases SNS outflow/renin activity) |
| What can abrupt discontinuation of clonidine lead too? | Rebound HTN/ST |
| What are some uses of Clonidine? | Pre-op sedative, withdrawal, Catecholamine Suppression test in DX of Pheochromocytoma, TX with alpha blocker 1ST (Prazosin) then beta blocker. |
| 3 ways to block the action of Clonidine? | A2 antagonist: Regitine, A1 agonist: Neosynephrine, B1 agonist: |
| Regitine Class and name? | Alpha Antagonist (Phentolamine) |
| Regitine Dose/Onset of Action | Rapid onset, short duration, used for Pheochromocytoma HTN (1-5mg slow IVP) |
| What can Regitine also be used for? | Vasoconstrictor local infiltrates (5-10mg/10ml and injected SC) |
| What class is Droperidol? Other name? | Alpha Antagonist / Inapsine |
| What type of drug is Droperidol and what is it used for? | Butyrophenone / Antiemetic, Mild decrease in BP |
| What are some side effects with Droperidol? | Prolonged QT / Leads to Vtach |
| What are Beta 2 Agonist used for? | COPD, Asthma, Bronchospasm, premature labor, |
| Some Beta 2 Agonist drugs? | Metaproterenol (Alupent), Albuterol (Proventil, Ventolin), |
| Which two Beta 2 Agonist are used for OB? | Terbutaline (Brethine) 0.25mg SQ, Ritodrine Hydrochloride (Yutopar) |
| Which Beta 2 agonist is the only one approved for labor use in the US? | Ritodrine Hydrochloride (Yutopar) |
| Chronic use of Beta 2 agonist can lead to what due to what? | Tachyphylaxis due to down regulation, and also an increased airway hyperresponsiveness. |
| Down regulation causes (sensitization/desensitization)? When can it occur? | Desensitization / 1-6 hours of use. |
| Beta antagonist therapy leads to what regulation? | Up regulation / Sensitization |
| What are some beta antagonist uses? | Angina Pectoris/MI, HTN, SVT, Vdys, WPW syndrome, afib, Cardiomyopathies, preop hyperthyroid pts, Dig induced dys, Migraines, nervousness |
| Some problems with beta antagonist use? | Bronchospasm (non-selective), Cardiac failure, Potentiates peripheral vasoconstriction, hyperkalemia. |
| What patients should avoid beta antagonist medication? | PVD & Raynaud's disease DM (mask hypoglycemia and can prevent increase in serum glucose levels) |
| What can abrupt discontinuation of beta antagonist cause? | Withdrawal syndrome, increases SNS activity |
| Should we continue Beta antagonist therapy preoperatively? | YES |
| How can beta antagonist be subdivided? | Selectivity for cardiac beta 1 receptors |
| What is unique about beta antagonist selectivity? | As dose increases, selectivity diminishes. |
| What does Beta 1 receptor blockers cause? | Decreases HR, contractility |
| What does Beta 2 blockers cause? | Unwanted bronchospasm, Peripheral vasoconstriction- Propanolol(Inderal), Nadolol(Corgard), Timolol(Blocadren) |
| Propanolol Onset/HL/Dose | 15 min, 4 hour HL (longer in hepatic pts.), 1-5 mg IV (start with 0.25-0.50mg) |
| Esmolol Onset/HL/DOA//Dose/Metabolism | 2 min, 9 min HL, 10-15 min DOA, 500mcg/kg loading dose then 100-300mcg/kg/min, Bolus: 10-30 mg PRN, Plasma esterase |
| Labetalol names? | Normodyne, Trandate |
| Labetalol class | Non-selective beta blocker |
| Labetalol beta/alpha blockade ratio? | 7:1 |
| Is Labetalol good for anesthesia? | No, last 12-18 hours |
| Labetalol dose/metabolism | 0.25mg/kg IV, Infusion 2mg/min, Bolus 5-10 mg, Hepatic/renal |
| What must a patient have before giving labetalol? | Adequate HR |
| What are examples of direct vasodilators? | Sodium Nitroprusside, Nitroglycerin, Hydralazine |
| The action of direct vasodilators? | Increases the concentration of nitric oxide. NO stimulates guanylate cyclase to produce cGMP, which activates protein kinase. |
| Sodium Nitroprusside uses | HTN, to induce hypotension to prevent blood loss, Pulm edema, blunt intubation 1-2mcg/kg |
| Sodium Nitroprusside Onset/concentration/dose/duration | seconds, 25-50ml/500ml D5W, 25mcg/kg or 0.5mcg/kg/min, 1-3 min |
| Pharmacological effects of Sodium Nitroprusside | Greater Arterial: decreases preload,after load,O2 consumption |
| Some issues with Nipride? | Light sensitive, coronary steal, cyanide toxicity |
| What dose can cyanide toxicity occur? | > 8mcg/kg/min (0.5mg/kg/hr) |
| Metabolic acidosis from cyanide poisoning can be expressed as what two conditions? | Moderate: base deficit not worse than -10, VSS or Severe: base deficit > -10, unstable |
| TX for Cyanide toxicity? | Stop drug, give 100% O2, correct acidosis, Sodium Thiosulfate 150mg/kg IV repeat q 10 min for 3-4 doses |
| How to treat severe Cyanide toxicity? | Stop drug, 100% O2, correct acidosis, Sodium Nitrate 5mg/kg IV |
| What else can be done for severe Cyanide toxicity? | Break ampule of amyl nitrate in breathing bag, creates methemoglobin which excess cyanide ions can bind. |
| Nitroglycerin effects? | Greater venous dilation / Arterial dilation at high doses. |
| Nitroglycerin uses | Angina pectoris, ischemia, biliary spasm, HTN, "unloading" of the heart with CHF/MI |
| Nitroglycerin Side effects | pulsating HA, increased HR, ST depression if very large decrease in BP |
| 3 NTG effects overall | Increase O2 supply (vasodilation), Decrease work theory, smooth muscle relaxation |
| Sublingual NTG dose | 0.4mg q 5 min x 3 |
| IV NTG concentration/dose | 50mg/250ml, 5-10 mcg/min titrate q 1-2 min |
| Hydralazine effects? | Arterial relaxation only |
| Hydralazine uses | HTN |
| Does hydrazine cause HR changes? | NO |
| Hydralazine dose/onset/HL/DOA | 2.5-20mg IV, 2-20 min WAIT FOR RE-DOSING, 1 hour HL, 12 hour duration |
| Hydralazine side effects | ST depression from decrease BP, Lupus syndrome, N&V (Zofran) |
| How do CCBs work? | Depress electrical impulses in the SA/AV nodes |
| How do CCB effect inotropy and chronotropy? | negative effects |
| CCB indications | Prinzmetal's Angina, HTN, Atrial tachycardia, Post CABG when radial artery used as graft to prevent vasospasm. |
| Avoid CCB in which patients? | Wide complex tachycardia, Afib associated with WPW syndrome, Simple atrial tachycardia, CHF, Sick sinus syndrome |
| Combining CCB with which medication can lead to which complication? | Fentanyl / bradyarrhythmias |
| When would you only use CCB and beta blockers together? | IHSS (Idiopathic Hypertrophic Subaortic Stenosis) decreases HR and contractility |
| CCB can influence which medication? Which CCB specifically? | CCB can increase dig levels by 30-70%, especially with Calan(Procardia) |
| CCB Examples | Nifedipine(Procardia/Adalat), Nicardipine (Cardene), Diltiazem, Nimodipine, Verapamil |
| Which CCB treats atrial tachydysrhythmias? Dose | Verapamil IV 2-5mg, q 30min, onset 10min, duration 2-4 hour |
| Which CCB treat cerebral vasospasms? | Nimodipine |
| Which CCB treat angina? | Nifedipine/Diltiazem |
| Which CCB treat HTN is neroanesthesia? | Nicardipine |
| Which CCB is used to stop labor? | Nifedipine |
| Nifedipine dose | 10mg SL onset 10-20 min, duration 2-3 hours |
| What do ACE inhibitors treat? | CHF/HTN/Post MI |
| How do ACE inhibitors work? | Block converse of Angiotensin I to Angiotensin II |
| ACE inhibit examples | Catopril (Capoten), Enalapril (Vasotec), Lisinopril (Prinivil, Zestril) |
| ACE inhibitor side effects | Cough, angioedema, hyperkalemia |
| What problem could occur with ACE inhibitor and anesthesia? | Refractory hypotension / bradycardia |
| Angiotensin II receptor blocker effects? | Directly blocks angiotensin II effects |
| How does ARBs compare to ACE inhibitors? | ARBs prevent buildup of bradykinin and prostaglandins and prevents cough. |
| ARB examples | Saralasin(Serenin), Losartan |
| How many Antidyrhythmic Classes are there? | 4 |
| How many Class 1 antidysrhythomics are there? | 3 |
| Class 1 Antidysrhythmics | Sodium Channel Blockers |
| Class 1A drugs | Quinidine, Procainamide, Norpace |
| Class 1B drugs | Lidocaine, Tocainide, Dilantin |
| Class 1C drugs | Flecainide, Encainide |
| Class II Antidysrhythmics | Beta Blockers |
| Class III Antidysrhythmics | Potassium Channel Blockers |
| Class III drugs | Bretylium, Amiodorone |
| Class IV Antidysrhythmics | Calcium Channel Blockers |
| What is the resting potential of the cardiac ventricular cell? | -90 mV |
| Pase 4 represents? | Diastole / resting membrane potential Na+/K+ ATPase pump restore levels. |
| Phase 0 represents? | Rapid depolarization, opening of fast Na+ channels, Na+ into cell. |
| Phase 1 represents? | Brief repolarization, CL- channels open move into cell, Na+ channels close, K channels open and K+ moves out. |
| Phase 2 represents? | Plateau, Calcium moves into cell, K moves out. |
| Phase 3 represents? | Repolarization, Calcium channels close, K continues to move out. |
| How effective are class 1A/B/C Na+ Channel Blockers? | 1B: Weak (decrease ERP), 1A: Moderate (increase ERP) 1C: Strong (no change in ERP) |
| What does Quinidine treat? | Supraventricular arrythmias, slows afib rate |
| What can be effected by Quinidine | Potentiate NMBs |
| What can Procanamide treat? | Ventricular Tachydysrhythmias |
| What is a problem with chronic use of Procanamide? | Lupus |
| What does Lidocaine treat? | Ventricular dysrhythmias (PVC/VT) |
| How does Lidocaine treat PVCs? | Delaying phase 4 depolarization and decreasing K+ ion permeability |
| Lidocaine dose | Bolus 2mg/kg Infusion 1-4mg/min |
| What does Amiodarone Treat? Doses? | Supraventricular Tachydys 200mg PO, Ventricular tachydysrhythmias 400mg PO, IV 5mg/kg over 2-5 min effective for 4 hours |
| How does Amiodarone effect the cardiac cycle? | Prolongs ERP |
| What can Amiodarone do to the heart? | Prolongs QT interval, Torsades de pointes |
| How do you treat Torsades de points? | Magnesium |
| What is Bretylium used for? | refractory vent dysrhythmias |
| Bretylium dose? | 5-10 mg/kg IV MAX 30mg/kg |
| What patients would Bretylium be used with caution? | Renal patients |
| What type of drug is Adenosine? | Endogenous Purine Nucleoside |
| How is Adenosine formed? | Breakdown od ATP |
| How does Adenosine work? | Binds to type 1 A receptors in the myocyte coupled with Gi proteins, this activates the K channels to open causing hyper polarization due to K+ efflux. |
| With Adenosine, hyper polarization is seen with what? | Asystole |
| What part of the heart is decreased with Adenosine? | AV conduction |
| Adenosine Dose/HL | RAPID BOLUS 6 mg IV, followed by 12mg dose within 3 min. HL < 10 seconds |
| Where is Adenosine metabolized? | In the RBCs |
| What are the indications for Adenosine? | SVT, WPW |
| Adenosine Side effects? | Flushing, vasodilation |
| Adenosine is contraindicated with what patients? | 2nd & 3rd degree HB |
Created by:
gmg005
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