Anticoagulants & Procoagulants

Anticoagulants & Procoagulants

Primary Hemostasis Mechanisms

• Activation
• Adhesion
• Aggregation

Platelet Adhesion

• Requires exposure of the endothelial cell layer.
• Needs attachment factor VWF to collagen receptors.

Platelet Activation Mediators

• ADP
• Thromboxane A2

Platelet Aggregation

• Fibrinogen links platelets together.

Secondary Hemostasis

• Formation of a cross-linked and water-insoluble fibrin clot.

Vitamin K Dependent Clotting Factors

• Factor 2
• Factor 7
• Factor 9
• Factor 10

Extrinsic Coagulation Pathway Initiator

• Tissue factor (Factor 3)

Extrinsic Coagulation Pathway

• 3 + 7 = 10

Intrinsic Coagulation Pathway

• 12, 11, 9, 8 = 10

Final Common Pathway

• 5 * 2 * 1 = 13

Prothrombin Time (PT)

• Measures the extrinsic pathway of coagulation.
• Normal PT value is 11-14 seconds.

Activated Partial Thromboplastin Time (aPTT)

• Measures the intrinsic pathway of coagulation.
• Normal aPTT value is 25-35 seconds.

Activated Clotting Time (ACT)

• Measures the activity of Heparin and Fonda drugs
• Involves the intrinsic and common pathways.

Unfractionated Heparin Mechanism of Action

• Strengthens antithrombin III (AT3).

Unfractionated Heparin Hold Time

• Hold for 4-24 hours before neuraxial anesthesia for a therapeutic dose.

Heparin-Induced Thrombocytopenia (HIT) Pathophysiology

• Antibody against factor 4.

Low-Molecular-Weight Heparin Risk

• Risk of spinal and epidural hematoma.

Warfarin Mechanism of Action

• Inhibits Vitamin K epoxide reductase.
• Inhibits factors 2, 7, 9, and 10.

Warfarin INR Target Value

• 2-4

Warfarin Hold Time

• Hold for 4 days prior to surgery.

Bivalirudin and Argatroban

• Inhibit factor 2.

Xarelto and Apixaban

• Inhibit factor Xa.
• Reduce the risk of stroke in patients with atrial fibrillation.

Aspirin Mechanism of Action

• Blocks Cox 1 and 2 and inhibits Thromboxane A2.

Clopidogrel Discontinuation

• Discontinue for 5-7 days before surgery and regional anesthesia.

Plasminogen Activator Thrombolytics

• Contraindicated within 24 hours of neuraxial and regional anesthesia.

Antithrombin III Function

• Binds to platelet factors and deactivates them.

Antithrombin III as a Cofactor

• Is a cofactor for Heparin

Plasminogen Activators

• Increase the formation of plasmin leading to breakdown of the fibrin clot.

Epsilon Aminocaproic Acid (Amicar) Mechanism

• Binds to plasmin and inhibits it.

Tranexamic Acid (TXA) Mechanism

• Inhibits plasmin.

Protamine Mechanism of Action

• Reverses unfractionated Heparin.
• It is a basic drug
• Not effective against low molecular weight Heparin.

Protamine Side Effects

• Hypotension
• Anaphylaxis
• Issues for patients using NPH insulin
• Right side HF
• Acute Pulmonary Vasoconstriction

Desmopressin (DDAVP)

• Given in a dose of 0.3 over 15-30 minutes.
• Releases endogenous stores of Factor 8 or vWF.

Cryoprecipitate

• Given to treat low fibrinogen levels.
• 1 unit/10 kg increases fibrinogen levels by approximately 50-70 d/l.

Fluids/Electrolytes/Blood Worksheet

Major Intracellular Ions

• Potassium is the major cation.
• Phosphate is the major anion.

Major Extracellular Ions

• Sodium is the major cation.
• Chloride is the major anion.

Barriers to Protein Movement

• Cell membrane
• Glycolax layer

Static Parameters for Volume Monitoring

• Urine output
• HR
• RR

Dynamic Parameters

• Greater than 10-12% variation in dynamic parameters such as pulse pressure variation with respiration indicates fluid replacement will be appropriate

Balanced Crystalloid

• Lactated Ringers (LR)

Strong Ion Difference (SID)

• Positive and Negative ions.
• Alkalosis if SID is high (↑ Na⁺, Ca²⁺, K⁺, Phos⁻).
• Acidosis if SID is low (↑ Cl⁻, Lactate from LR).
• A decrease in the SID has what effect on pH? Acidosis
• A decrease in the SID may occur following excessive infusion of what fluid? NS

Intravascular Crystalloid Percentage

• Approximately 20% of infused crystalloids remains intravascular in healthy patients.

Hypotonic Crystalloids

• ½ NS
• D5 in Water
• Water moves into the cell.

Hypertonic Crystalloids

• 3% NS
• D5W in NS
• Water moves out of the cell.

Colloids

• Fluid solutions containing large molecular weight particles suspended in a crystalloid solution.

Albumin Infusions

• Anaphylactoid reactions are not common.

Hydroxyethyl Starches (HES) Black Box Warning

• Renal failure patient
• Heart failure patient
• Critically ill patient
• Open heart patient
• Coagulopathy patient

Colloids vs. Crystalloids

• No substantial high-quality evidence suggests colloids are superior to balanced crystalloids for intravascular fluid volume status.

Sodium Functions

• Compartmental water balance & osmolality.
• Membrane potential for excitability.
• Tissue excitability.

Potassium Functions

• Cell membrane excitability
• Vasodilation
• Clot formation
• Renal function.

Drugs Causing Decreased Potassium Levels

• Insulin
• Sodium bicarb
• Kayexalate
• Dialysis
• Furosemide
• Calcium
• Beta agonist

Magnesium

• Used to treat preeclampsia (pregnancy complication).

Calcium Chloride vs. Calcium Gluconate

• Calcium chloride contains 3x more elemental calcium per ml than calcium gluconate.
• Risk of extravasation with calcium chloride in small, peripheral IVs.

Blood Cell Production

• Kidney and bone marrow are the main sources.

Agglutinogen

• An antigen that can form agglutination when exposed to an antibody.

Agglutinin

• Formation of agglutination.
• Blood clot and adverse effect of blood incompatibility is the ultimate risk of agglutination.

Depleted RBC Substances During Storage

• ATP
• 2,3 DPG

IV Fluids to Avoid with RBC Transfusion

• D5
• LR

Thawed Plasma Transfusion

• Transfuse within 24 hours.

Cryoprecipitate Factors

• Factor 1
• Factor 8
• Factor 13
• Should not be administered with platelet products.

Leukoreduction

• Reducing WBC to avoid inflammatory response or donor tissue rejection.
• Minimizes leukocytes.

Transfusion-Associated Circulatory Overload (TACO)

• Cardiogenic volume overload related to blood product transfusion.

Transfusion-Related Acute Lung Injury (TRALI)

• Pulmonary vascular injury and non-cardiogenic edema within 6 hours of transfusion.

Coagulopathies from Trauma

• Worsened by dilation coagulopathy and fibrinolysis.

Thromboelastography (TEG)

• Provides information on clot strength and formation.

Electrolyte Monitoring with Transfusion

• Replace and monitor calcium levels.

Massive Transfusion

• Administration of greater than 10 units of RBCs within 24 hours.

Massive Transfusion Ratio

• 1 PRBC: 1 Plasma: 1 Platelet (1:1:1).

Risks of Excessive Crystalloid Use

• Volume dilution
• Electrolyte imbalance

Crossword 1

• Balanced
• Citrate
• TACO
• Magnesium
• Hyperosmolar
• Bone Marrow
• Coagulopathy
• Macrophage
• Lipids
• Chloride
• Calcium
• HES
• Platelet
• Albumin
• Agglutinogen
• Lucoreduced / gama
• Acidosis
• Sodium
• Lactic
• Lysis

Crossword 2

• Vitamin K
• Protamine
• aPtt/ ACT
• Plasminogen
• INR
• Plasmin
• Intrinsic
• TxA
• Heparin
• Calcium
• Activation
• DDAVP
• Antithrombin
• TEG
• Factor 2
• Fibrinogen
• Extrinsic
• Clopidogrel
• Aspirin

Renal, F & E, Hematologic PBL in Pharmacology - Case Studies

Case 1: Renal - Diuretics 1

• 71-year-old Mrs. S - posterior fossa craniotomy.
• Cerebral edema, hypertension, and mild GERD.
• Weight 70 kg.
• Meds: levetiracetam, famotidine, metoprolol, hydrochlorothiazide.
• Neurosurgeon requests preoperative diuretic for cerebral edema management.

Diuretic

• The likely drug is Mannitol.
• Increased plasma osmolality pulls H20. scavenge free O2 radicals.
• PCT and DL.
• 1/g kg/ 10-15 min 60-90 min later before incision.
• 0.2-2g/kg range.
• May increase in plasma volume.

Case 2: Renal - Diuretics 2

• 41-year-old Miss Y - robotic hysterectomy.
• Uterine fibroids and smoking.
• Meds: cefazolin, fentanyl, propofol, rocuronium, sevoflurane.
• Surgeon desires urine production before discharge, requests low dose diuretic in thick ascending limb.

Mild Diuretic

• Loop Diuretic – Furosemide – 10 - 20 mg.
• Cefazolin – nephrotoxic and autotoxin drug with Prop and Roc, Fentanyl.
• Ototoxicity and Tinnitus due to receptors.
• Hypovolemia, Hypotension, Hypokalemic, pre-renal, Nephrotoxic effects.
• Acetylcysteine (Mucomyst) – If nephrotoxicity is suspected.
• Addition of thiazide for RASS activation.
• Fluids - LR - NS.
• Possible RAAS – resistance.
• Repeat dose 20-40 mg.

Case 3: F & E – Fluid Management

• 60-year-old Ms. E - open femur reduction.
• Uncontrolled HTN and chronic renal insufficiency.
• Estimated blood loss 100 ml, H/H 9/27.
• Two PIVs, one in each hand (20 g, 18 g).
• VS – sinus rhythm (85), BP (85/60), O2 sat 97% (on vent)

Fluid management

• 80% interstitial and 20% plasma.
• PP variation.
• 200-500 LR. Yes Bp 85/60 hypotensive and 15% PPV suggest fluid responsiveness.
• PRBC vs colloids give 2 units PRBC to increase H/H approx. 2/6. Would have given Albumin if pt was Young
• LR lacks Calcium and NS based on lack of Potassium.
• Potassium leak.
• Calcium gluconate 1–2-gram IV dose range 0.5-2g.

Case 4: F & E – Transfusion Management

• 20-year-old Mr. L - trauma patient.
• Active abdominal bleeding.
• Received 2 liters of normal saline and 2 units of PRBCs prior to arrival.
• VS – sinus tachycardia w/PVCs (138), BP (77/50), O2 sat 92% (ambu), temp 34.5 deg C; pH 7.25, HCO3- 18, CO2 55, lactate 4 mmol/L

Transfusion Management

• PRBC, Cyro, Platelet.
• 10 units in 24hr.
• NS, Plasmalyte or Norm sol.
• Give FFP, Prioritise Blood products.
• 154 and 4.
• 1 gram TXA, Calcium chloride 1 gram for 3 blood products.

Case 5: Hematology – Anticoagulants 1

• 24-year-old Miss O - laboring patient.
• History of vape use and DVTs.
• Meds – PO prenatal vitamin, SC prophylactic low-molecular-weight heparin (last dose 8AM).

Anticoagulant

• 6 pm 10-12 hrs.
• Epidural Hematoma.
• No. HIT has antibodies in platelet factor 4.
• Xa monitor.

Case 6: Hematology – Anticoagulants 2

• 55-year-old Mrs. U - arteriovenous fistula revision surgery.
• Chronic renal failure with hemodialysis, atrial fibrillation, transient ischemic attack (x2), peripheral edema, and uncontrolled hypertension.
• Meds – torsemide, warfarin, amlodipine

Anticoagulant 2

• Friday morning at the latest or Wednesday preferred.
• 100%.
• Extrinsic and common.
• She urgently needs this revision to receive dialysis later today.
• Fibrin sealant (Biologic glue).

Renal Pharmacology Crossword

• Across:
  • PCT
  • Osmolality
  • Methemoglobin
  • Negative
  • Ileus
  • ENAC
  • Aldosterone
  • Loop
  • Mannitol
  • Metabolic Acidosis
  • ANP
  • Renin
• Down:
  • Hypokalemia
  • Prostaglandins
  • ICG
  • Diphenhydramine
  • Bicarbonate
  • Contrast-Induced Nephropathy (CIN)
  • Fenoldopam
  • Alkalosis
  • Inert
  • Calcium

Renal (Diuretics) Worksheet

Kidney Hormones

• Calciterol
• Renin
• Erythropoietin

Cardiac Output

• Kidneys receive approximately 25%.

Aldosterone Effects

• Distal absorption of Na+ and water
• Excretion of K+.

Renin-Angiotensin-Aldosterone System Activation

• False, so Hypovolemia, Hyponatremia is right answer
• Activated by Hypovolemia, Hyponatremia.
• Juxtamedullary cell release renin
• Angiotensin II causes vasoconstriction.

Kidney Reabsorption

• Reabsorb NaCl and water

Vasopressin and Aldosterone Release

• Accompanies Hyperkalemia, Hypovolemia change in blood volume.

Atrial Natriuretic Peptide (Factor) Function

• Vasodilation, natriuresis, and diuresis.

Acid-Base Balance

• Peritubular capillaries reabsorbing Bicarb ions into the plasma.
• Secreting Hydrogen ions into the lumen filtrate.

First Step of Urine Formation

• C filtration

GFR

• Dilating (↑) afferent arteriole tone increases GFR.
• vasconstriction (↑) efferent arteriole tone increases GFR.

Sodium Movement

• Water tends to follow sodium.

Reabsorption Mechanisms

• The sodium-potassium pump is an example of a ATP or active mechanism of reabsorption.
• Osmosis is an example of a passive mechanism of reabsorption.

Common Diuretic Uses

• CHF
• HTN

Carbonic Anhydrase Inhibitors

• Primarilly decrease the reabsorption of Bicarb, Na, and H20

Osmotic Diuretics

• They innate (no change)
• Increase the osmolality of blood and renal tubule fluid.

Mannitol Dose

• 0.25-1 g/kg IV

Loop Diuretics

• Inhibit the Na/K/2Cl co-transporter in the Ascending thick limb of the loop of Henle.
• Increase prostaglandin production.

Loop Diuretics and Potassium

• Hypokalemia leads to metabolic alkalosis

Ototoxicity

• Loop Diuretic

Thiazide Diuretics

• Inhibit the Na/Cl co-transporter in the DCT tubule.
• Inhibit reabsorption & increase excretion of Na and Increase excretion of Na and H20.
• Increase reabsorption of calcium.

Blood Glucose

• Increase due to hyper uric acid and Ammonia.

Spironolactone Mechanism

• Block aldosterone receptor

Triamterene Mechanism

• Block Na channel directly in the endothelial. ENAC inhibitor.
• Collecting Duct a -Potassium-sparing diuretics primarily work where in the nephron?

Dopamine Receptors

• Activation of D1 receptors by dopamine increases formation of what cellular 2nd messenger? Cyclic AMP increase

Beta receptors

• Higher doses of dopamine agonists activate D1 adrenergic receptors increasing inotropy and cardiac output and B2 adrenergic receptors causing vasoconstriction.

Electrolyte Changes

• Loops: Decrease potassium, sodium, magnesium and calcium.
• Thiazides: Decrease potassium, sodium and magnesium, increase Calcium.
• K+ Sparing: Increase potassium, Decrease sodium.

Risk Factors for Kidney Injury

• Age
• CHF
• Surgical procedure being in peritoneum

Nephrotoxic Drug Classes

• Aminoglycoside
• Cephalosporin

Chemotherapeutics Worksheet

Cell Cycle Phases

• G1
• S
• G2
• Mitosis- Prophase/Metaphase/Anaphase/Telophase
• G0 is a “resting” cell phase.

Phases of Mitosis

• Prophase: Chromatin condenses into distinct chromosomes, which migrate towards the center of the cell. The nuclear envelope breaks down, and spindle fibers form.
• Metaphase: The nuclear membrane disappears, the spindle develops, and chromosomes align.
• Anaphase: Paired chromosomes (sister chromatids) separate, and spindle fibers lengthen the cell.
• Telophase: Chromosomes are sectioned off into two distinct new nuclei with equal genetic content. Cytokinesis (division of the cytoplasm) begins after anaphase and finishes after telophase, forming two new cells.

Malignant Cells

• Escape normal mechanisms for control of cellular division and growth True.

Metastasis

• Malignant cell migration and invasion of other tissues.

Important Tumor Suppressor

• C- P53

Telomeres

• DNA “end caps” which lead to cellular aging

Chemotherapy Toxicity

• Toxicity side effects are often related to rapidly dividing cell targets. Normal dividing cells like hair follicle and mucosal cell

Anesthetic Considerations for Immunosuppressed Cancer Patient.

• Carry Aseptic methods
• Use prophylactic antibiotics

Alkylating Agents

• Act does not work on the cell –cycle phase Pulmonary side effects are Pneumonitis/Fibrosis/Decreased diffusion capacity.
• Inhibit plasma cholinesterase activity.
• Cardiotoxicity like Cyclophosphamide

Platinum Complexes

• Works on solid tumor.
• Mechanism of action is cross linking in DNA – disrupting its replication and division like Alkylating-like effect.
• Cisplatin causes nephrotoxicity (Block box warning), ototoxicity, peripheral neuropathy (Block box warning), Marked nausea and Vomiting (Black box warning), myelo suppression, and hypersensitivity reactions

Antimetabolites

• Mimic cellular nutrient and inhibiting enzymes – nucleobases and dermatologic side effect Drug dermatologic side effects - Dermatitis/Pigmentation changes/Nail changes/Alopecia/Photosensitivity Other side effects - Bone marrow suppression, pulmonary toxicity, GI toxicity (stomatitis, ulceration, diarrhea, hemorrhagic enteritis, perforation), nephrotoxicity, hepatotoxicity (cirrhosis risk), CNS effects (cerebellar syndrome, drowsiness, fatigue).

Topoisomerase Inhibitors

• Inhibits action of DNA.
• Heart condition commonly caused by antitumor antibiotics like daunorubicin and Daunorubicin is CardiotoxicityMechanism for this cardiotoxicity is free radicals disrupt critical cardia proteins and cell membrane components
• Pulmonary effect with Bleomycin is Pulmonary toxicity Anesthetic consideration of Minimizing crystalloids, considering colloids, and keeping FiO2 low (below 30% if possible – normal to room air)

Microtubule action effects

Microtubule inhibitors are active in M phase

• Vinca Alkaloids
• Taxanes Neuromuscular side effects of Microtubule sensory- motor neuropathy, areflexia, Paresthesia’s, Skeletal weakness, skeletal muscle pain, Ataxia Dexamethasone for edema and effusion Regional anesthesia in the patient taking microtubule inhibitors may worsen neuropathy.

Signal Transduction Modifier Hormones

Monoclonal antibodies target Autoimmune targets Autoimmune disease target specific cancer antigens or receptors · Autoimmune diseases monoclonal antibodies can treat Multiple sclerosis & rheumatoid arthritis · Hormones that have been associated with thromboembolic events and stroke Anti- estrogens like Tamoxifen (Boxed warning)

· Vaccines use Decrease the risk of having that cancer

MEMEORY

· Bleomycin damage to Pulmonary damage to due to free radical production in the presence of oxygen and iron/copper, causing endothelial and epithelial damage, leading to pulmonary fibrosis · Recommended O2 concentration for patients taking bleomycin is Not a 100 but above 90 (lower inhaled oxygen concentrations (below 30%) to avoid exacerbating lung damage in patients taking bleomycin. Source also mentions Maintaining O2 saturation over 90%,) · Cisplatin is toxic to Black box warning - vomiting/hypersensitivity reaction/ Myelosuppression/ Otoxicity · Doxorubicin Cardiotoxicity - -due to free radical formation disrupting cardiac proteins and cell membranes, leading to dose-related cardiomyopathy and arrhythmias

Immunologic Pharmacology Crossword

Across

• Corneal
• Vancomycin
• Macrolides
• Class 1
• 16 ciprofloxacin
• 20 aminoglycoside
• One
• Resistance
• Cefazolin or Metronidazole

Down

• Positive
• Bera lactam
• Trough
• Clindamycin
• Weakmess
• Cefepime

Immunologic Worksheet

Antimicrobials

What are the 3 types of surgical site infection?

• Superficial Incisional, Deep Incisional, Organ/Space

Name 3 endogenous risk factors for the development of an SSI. a. Corticosteroid use b. Preop skin prep (e.g. clipping, scrubbing c. Prolonged hospital stays d. Extremes of age e. Poor nutritional status f. Obesity g. Diabetes, Poor Perioperative glycemic control. h. Peripheral Vascular disease, i. Tobacco use (stopping 4-6 weeks before the surgery time) j. Current infection, k. altered immunity, corticosteroid use, l. Higher American Society of Anesthesiologist physical Status score m. Recent radiotherapy n. Hx of skin or soft tissue infection o. Obesity, alcoholism, preop albumin 1.0 mg/dl Immunosuppression

What is wound classification Class II called? i. Clean Contaminated and Usual sites are respiratory, gastrointestinal (GI), or genitourinary (GU) tracts

The SCIP-1 measure states vancomycin should be infused within 2hrs hours before incision.

Name 2 classes of beta-lactams. Carbapenems Monobactams Carbacephems Oxacephems Clavams SCIP-2 says antibiotics should be discontinued within 24hrs hours after surgery. When bacteria produce enzymes which can break down the structure of antibiotics, this is known as Bacterial Resistance. For beta-lactams, the enzyme is called Beta Lactamases True/False. Patients with a family history of penicillin allergy will inherit the allergy. False - inhibition of protein synthesis is drug of choice and surgical prophylactic is Cefazolin (Ancef) the dose IV dose in the patient who weighs 135 kg is 3g IV for pt >120 Kg

• Gentamicin and classes aminoglycosides. Binding to the 30S ribosomal subunit of bacteria

Which common perioperative antibiotic belongs to the lincosamide class? Clindamycin (Cleocin) infused over minutes 10 to 60 recommended is 30 minutes.

Name 3 symptoms of red man syndrome Erythema, Pruritus, Hypotension

What are the side effects from administering metronidazole with alcohol? Abdominal disturbances, Nausea, Vomiting, Headache, and Flushing

Name 3 topical antiseptics used perioperatively. a. Chlorhexidine (Betadine, DuraPrep) b. Povidone Iodine (Betadine, DuraPrep) c. Iodine

Antiretroviral drugs

Which stage of HIV infection is associated with fever, chills, and muscle aches? a. How long does this stage last

entry inhibitors that block viral entry into entry into which cells

• Zidovudine (AZT) competitively inhibits which enzyme? -True/False. AZT can be used in the HIV management of pregnant patients. Which class of antiretrovirals require a boosting agent
• Name 2 anesthetic drugs which may be preferred to minimize drug interactions with these. Respiratory drugs crossword

Across

• Infection and hyperglycemia are common side effects of this class of respiratory drugs
• Airway fibrosis, alveolar destruction and mucus hypersecretion develop in this respiratory disorder
• This may occur during light anesthesia (esp. in inflammatory airway disease) requiring use of bronchodilators
• This IV anesthetic decreases pulmonary arterial pressure
• Albuterol can cause this side effect related to skeletal muscle stimulation
• Cromolyn sodium blocks degranulation of these inflammatory cells
• Beta-2 receptor agonism leads to vascular and bronchial smooth muscle _______________ -Ipratropium may cause this common cardiovascular side effect
• Work of breathing is increased as you decrease compliance and/or increase _______________
• Fluticasone is an inhaled corticosteroid that can be used alone to decrease inflammation in this disease
• This inhaled drug directly increases guanylyl cyclase and relaxes smooth muscle

Down

• Theophylline blocks this enzyme
• Shunting is an example of mismatch between ventilation and __________________
• This volume represents small airway collapse at low lung volumes
• COPD patients experience an increase in this V/Q mismatch during sleep
• Montelukast blocks conversion of arachidonic acid to these mediators
• This volume is left in the lungs after maximal expiration
• This preservative in propofol antagonizes its ability to block bronchoconstriction

Respiratory Worksheet

• FRC Volume of air is at lung and use PEEp to improve on this volume
• General anesthesia can cause partial alveolar closure or collapse known as atelectasis

Compliance

• Change in lung volume for a given value Turbulent air flow and decreases in lung volumes increase airway resistance Physiologic Dead space = inspired air that does not enter (or participate in) gas exchanging alveoli

• Shunt-Venous blood that returns to the heart without exposure to ventilated alveoli.

• More O2 is offloaded to tissues (decreased affinity shifts RIGHT side with acidotic/ hyperthermia and increase of DPG

An oxyhemoglobin dissociation curve shift to the LEFT indicates an increased affinity for oxygen binding by hemoglobin.

• 3 situations Hypothermia or Fetal hemoglobin or Alkalosis or Low DPG

• COPD Elevate Paco2 & characterized with low low FEV1/FVC ratio and decreased Forced expiratory volume,Restrictive airway disease is characterized by a normal FEV1/FVC ratio and decreased forced expiratory volume. Asthma - is characteristized with inflammatory airway disease characterized by bronchospasm, edema, mucus secretion and proliferation of smooth muscle cells

Low flow oxygen delivery device - nasal canula & High Oxygen delivery devices Venturi mask delivery

• Parasympathetic nerve Vagus. with neurotransmitter ACH activating the M 3 receptor resulting on bronchial constrictions

Sympathetic influence Airways Direct Muscle relation through B2 by NANC is in smooth relaxation, Shark Fin (More repsiratory rate)

Beta 2 agonist

• Increase intracellular cAMP levels in smooth muscle vasodilation/broncodilation and tachycardia

Initial Acute bronchospasm is 4 to 6 Puff 15 Q 90 MCG Mucaranic antagonist blocks and decrease Ca + w/ Ipratro Theophyllene blocks both The toxicity is above 20 with Immunocompromisedinfoection and Hyperglacemia/ and Osteoprosis

Propofol - and Ketamine cause Bronco Dialation and Vascular Vascular with alpa 2 prostacyin /endothelin

CG MP effect ca inhibitors

• k hyper polarization and activations

-Pulmonary hypertention is above 20 and Use sildenafil and Anticholinergics

E popro

• increase the hormone which targets IP receptors gs protein – increase cAMP – smooth muscle relaxation = vasodilation Prostacycline

NEURO PHARMACOLOGY CROSSWORD

• 6. Bradykinesia 9. Decrease 13. Droperidol 14. Dopamine 15. Glutamate 17. Post-dural 18. Hypoglycemia 19. Basal ganglia 22. Inactive 24. Inducers
• 1. Keppra 2. Doxpram 3. Lewy bodies 4. Gabapentinoids 5. Tumors 7. Extrapyramidal 8. NDMR’s 10. HOTN 11. MAOI 12. Valproic Acid 16. Beta-blocker 17. Phenytoin 20. Diazepam 0.1mcg/ml Q 10 minutes not exceeding 30 mcg 21. Levodopa 23. Status epilepticus

NEURO PHARMACOLOGY WORKSHEET

Anti-Parkinsonian Restin tremors with stiffness / rigidity b/ bradykinesia and an unstable gate/shuffle Dopamine depletion/ excess of AcH activity Anesthesia consideration are Rigid & Bradykinesia of respiratory and pharyngeal muscles avoid Beta Blockers Cardiovascular side effects of Levodopa are Orthostatic hypotension & tachycardia Parkinsoniasm gives Levodopa for support care with AC and PLC

• MAO-B antagonize the MOB from breaking down Dompamine & balances it with Anti cholestering
• Anti emetic use DROPERIDOL not Anti epileptics and possible symptoms will give Loss of convulations and focal movements seizure, Aura - Postictal states promote spreads by hypo w/ dec and inc Increased dose of propofol /Midazolom Seizure is gaba inhibitor GABA will have no effect on kePpRa Keppra -htn decrease with dec Will need I’me Induce - will need inc CNS & down regulates catecholamine w/ Phenylephrine/ epi and vaso Stimulating Medullary with carid chemo - doxepam. Methylxanthines of effect adenosine / activates

What drugs can been given post duel to meth ·PSYCHOPHARMACOLOGY CROSSWORD Acros ·a muscle relax that can be given to neuropleptic is dantrolene

· Typical

• A extra paramidal caused the hypotalaum / extrapyamidal caused with BP

· Anticholinergic affects side effects · Avoid KETAMINE serotonin/ lithium

• High food sodium
• Increase requirements
• Tyrmadine
• Serti line

PsychoPham

S- Regulation outside the CNS

• Peristalisis / Clitoting

CNS Regulation

• Affective /social / Conitive

Serotonon Reuptake Inhibitors

Increases serotonen at the synapse Srs Have a black Box that related to thoughts populations drug given during Anesthic periods autonomic change and neuromuscular abilities

SN R1

Venaiaxe blocks

T

And

Btc

Axe And b block A Anesthesia

Glaucoma and heart issues Mayo-block down syndrome

- lithium

Increases inhibition

Haloperio 30 Causes in volantaire Restless Mussel ridigity

Nm

Mh

NM - the drug list Methylphenahte and Anxierty

5-Dietary Supplements-

• *_ indications

• major elective major a or trauma Burns, hepatic dysfunction Placement of Tube is for period or Bowl Condition by rapid intro tube feeds : hyper stim-

• rapid administration of feeds can lead diarrhea Potential is pulmonary aspirations _should to for related long term Monitor fluids and electrolytes to the blood

• *_A,D,E and K

• Echinacea may cause with overactive autoimmune Cardiovascular is cause cardio instability- Should hold for garlic 35 hr or 7 days Warfarin with Ginger Ginkgo is increase bleeding Gluconse related can cause hypotemia

• is increase related to increase Used to is anixety

Endocrome

Pathway the is is homeostasis and released which pituitary Glucagon and the to reduce 23 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. .a 25. 26. Replace for ACTH release inhibit it Etomodate Vasopressin release. stim.a vasopress, cortisol of splancher blood flow Vasopporesion Refractiory HOTN activation of receptor smooth release inhibit, B and

.a 27. .a 28. 29. .a 30. .a 31. .a 32. 33. 34.

hormone release in b. what glands, the glands & hormones), a. .aa b. what is released the adrenal, what and, which in hormone 35. 36. 37. 38. 39. 40.

The

is a from the

what a/effect what does cause

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Gastrointestinal Pharmacology Crossword

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-Gastrointestinal Pharmacology WORKSHEET

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