Cardiac Effects of Tricyclic Antidepressants in Anesthesia
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Questions and Answers

Which type of agent may be the only effective management of hypotension in patients treated with TCAs?

  • Direct-acting agents like norepinephrine (correct)
  • Alpha-1 adrenergic antagonists
  • Centrally acting anticholinergics
  • Opioids and barbiturates

    • Why should the dose of exogenous epinephrine be adjusted in patients treated with TCAs during anesthesia with a volatile anesthetic?

  • To potentiate the effects of the anesthetic
  • To decrease blood pressure
  • To prevent cardiac arrhythmias (correct)
  • To avoid respiratory depression

    • Which anticholinergic agent is theoretically less likely to interact with TCAs and cause postoperative delirium and confusion?

  • Scopolamine
  • Atropine sulfate
  • Glycopyrrolate (correct)
  • Physostigmine

    • What potential risk is associated with giving TCAs in conjunction with alpha-1 adrenergic antagonists?

    <p>Increased risk of hypertension</p> Signup and view all the answers

    Why should the doses of opioids and barbiturates be decreased when used with TCAs?

    <p>To prevent exaggerated or prolonged depressant effects</p> Signup and view all the answers

    What makes TCA overdose life-threatening and able to progress rapidly?

    <p>CNS and cardiotoxicity</p> Signup and view all the answers

    When administering sympathomimetic agents to patients recently started on a tricyclic antidepressant (TCA), which of the following responses should be anticipated?

    <p>An exaggerated pressor response from direct-acting or indirect-acting sympathomimetics</p> Signup and view all the answers

    Which of the following statements is true regarding the administration of sympathomimetic agents in patients chronically treated with tricyclic antidepressants (TCAs)?

    <p>Conventional sympathomimetics may not be effective in restoring systemic blood pressure due to desensitization/down-regulation of adrenergic receptors or depletion of catecholamine stores</p> Signup and view all the answers

    When administering direct-acting sympathomimetics to patients on tricyclic antidepressants (TCAs) for more than 6 weeks, which of the following dosing strategies is recommended?

    <p>Decrease the initial dose to one-third of the usual dose as a precautionary measure</p> Signup and view all the answers

    Which of the following statements accurately describes the interaction between tricyclic antidepressants (TCAs) and indirect-acting sympathomimetic agents?

    <p>Pressor responses may be more pronounced with an indirect-acting agent such as ephedrine</p> Signup and view all the answers

    In patients chronically treated with tricyclic antidepressants (TCAs), which of the following mechanisms may contribute to the reduced effectiveness of conventional sympathomimetics in restoring systemic blood pressure?

    <p>Both desensitization/down-regulation of adrenergic receptors and depletion of catecholamine stores</p> Signup and view all the answers

    Which of the following statements accurately describes the interaction between tricyclic antidepressants (TCAs) and sympathomimetic agents?

    <p>The systemic blood pressure effects of administering sympathomimetics in patients treated with TCAs are complex and unpredictable</p> Signup and view all the answers

    Which enzyme systems are involved in the metabolism of Tricyclic Antidepressants (TCAs)?

    <p>CYP 450 enzyme system</p> Signup and view all the answers

    Which of the following is NOT a common cardiovascular effect of Tricyclic Antidepressants (TCAs)?

    <p>Hypertension</p> Signup and view all the answers

    What is the primary mechanism of action of Tricyclic Antidepressants (TCAs) in enhancing noradrenergic and serotonergic transmission?

    <p>Blocking NE and 5-HT reuptake</p> Signup and view all the answers

    Which of the following is a prominent adverse effect associated with Tricyclic Antidepressants (TCAs) at high doses?

    <p>Blurred vision</p> Signup and view all the answers

    What adverse effect can be life-threatening with Tricyclic Antidepressants (TCAs) overdose due to Na+ channel blockade?

    <p>Ventricular dysrhythmias</p> Signup and view all the answers

    Which side effect is NOT typically associated with Tricyclic Antidepressants (TCAs) use?

    <p>Headache</p> Signup and view all the answers

    What symptoms may occur upon abrupt cessation of Tricyclic Antidepressants (TCAs) treatment?

    <p>Nausea and chills</p> Signup and view all the answers

    Which type of Tricyclic Antidepressant (TCA) primarily inhibits the reuptake of norepinephrine?

    <p>Secondary Amines</p> Signup and view all the answers

    'Quinidine-Like effect' associated with Tricyclic Antidepressants (TCAs) refers to what cardiac issue?

    <p>'Long QT' syndrome</p> Signup and view all the answers

    'Inhaled anesthetics' are listed as a drug interaction caution with Tricyclic Antidepressants (TCAs) due to what reason?

    <p>Potential increase in TCA plasma exposure levels</p> Signup and view all the answers

    Match the Tricyclic Antidepressant (TCA) with its primary clinical use:

    <p>Amitriptyline (Elavil®) = Chronic neuropathic pain syndromes Clomipramine (Anafranil®) = Obsessive-compulsive disorder Imipramine (Tofranil®) = Enuresis Nortriptyline (Pamelor®) = Migraine prophylaxis</p> Signup and view all the answers

    Match the Tricyclic Antidepressant (TCA) with its mechanism of action:

    <p>Desipramine (Norpramin®) = Primarily inhibits the reuptake of norepinephrine Doxepin (Sinequan®) = Blocks the reuptake of both norepinephrine and serotonin Maprotiline (Ludiomil®) = Antagonizes alpha-1 adrenergic receptors Trimipramine (Surmontil®) = Inhibits reuptake of both norepinephrine and serotonin</p> Signup and view all the answers

    Match the Tricyclic Antidepressant (TCA) with its adverse effect:

    <p>Protriptyline (Vivactil®) = Orthostatic hypotension Amoxapine (Asendin®) = Anticholinergic effects like dry mouth and constipation Nortriptyline (Pamelor®) = Cardiac conduction abnormalities Trimipramine (Surmontil®) = Increased risk of seizures</p> Signup and view all the answers

    Match the Tricyclic Antidepressant (TCA) with its pharmacokinetic characteristic:

    <p>Imipramine (Tofranil®) = Long elimination half-life Amoxapine (Asendin®) = Extensive first-pass hepatic effect Maprotiline (Ludiomil®) = Highly protein bound Doxepin (Sinequan®) = Metabolized into active secondary amines</p> Signup and view all the answers

    Match the drug interaction caution with Tricyclic Antidepressants (TCAs) with the reason:

    <p>Sympathomimetics = May increase the plasma exposure of TCAs MAOIs = Never give at the same time as TCAs Inhaled anesthetics = Interaction caution due to unknown reasons Drugs inhibiting CYP 2D6 = Interfere with TCA metabolism</p> Signup and view all the answers

    Tricyclic Antidepressants (TCAs) are commonly used as first-line agents for depression due to their tolerable adverse effect profile.

    <p>False</p> Signup and view all the answers

    TCAs primarily inhibit the reuptake of serotonin only.

    <p>False</p> Signup and view all the answers

    Tricyclic Antidepressants (TCAs) have short elimination half-lives ranging from 1-12 hours.

    <p>False</p> Signup and view all the answers

    TCAs are metabolized in the kidneys rather than the liver.

    <p>False</p> Signup and view all the answers

    TCAs do not have any anticholinergic effects.

    <p>False</p> Signup and view all the answers

    Abrupt cessation of TCA treatment does not lead to withdrawal symptoms.

    <p>False</p> Signup and view all the answers

    Drug interactions with TCAs are not significant and do not require caution.

    <p>False</p> Signup and view all the answers

    Patients on TCAs should be given MAOIs simultaneously to enhance their therapeutic effects.

    <p>False</p> Signup and view all the answers

    Tricyclic Antidepressants (TCAs) can be safely used in patients with cardiac disease without monitoring.

    <p>False</p> Signup and view all the answers

    TCAs have no impact on the seizure threshold of individuals.

    <p>False</p> Signup and view all the answers

    Explain the 'Quinidine-Like effect' associated with Tricyclic Antidepressants (TCAs) and its clinical significance.

    <p>The 'Quinidine-Like effect' associated with Tricyclic Antidepressants (TCAs) refers to their ability to block sodium channels, similar to the antiarrhythmic drug quinidine. This can lead to cardiac conduction abnormalities, such as prolongation of the P-R interval, widening of the QRS complex, and prolongation of the QT interval, which can be life-threatening, especially in overdose situations. This 'Quinidine-Like effect' limits the use of TCAs in patients with pre-existing cardiac disease, as it increases the risk of ventricular dysrhythmias and other cardiac complications.</p> Signup and view all the answers

    What is the rationale for avoiding the concomitant use of Tricyclic Antidepressants (TCAs) and Monoamine Oxidase Inhibitors (MAOIs)?

    <p>The concomitant use of Tricyclic Antidepressants (TCAs) and Monoamine Oxidase Inhibitors (MAOIs) is strictly contraindicated due to the risk of a life-threatening serotonin syndrome. MAOIs inhibit the breakdown of monoamines, including serotonin, while TCAs inhibit the reuptake of serotonin and norepinephrine. The combination of these two mechanisms can lead to a dangerous accumulation of serotonin, causing severe and potentially fatal symptoms such as hyperthermia, autonomic instability, and neuromuscular abnormalities.</p> Signup and view all the answers

    Explain the mechanism by which Tricyclic Antidepressants (TCAs) can reduce the effectiveness of conventional sympathomimetic agents in restoring systemic blood pressure in patients chronically treated with TCAs.

    <p>In patients chronically treated with Tricyclic Antidepressants (TCAs), the reduced effectiveness of conventional sympathomimetic agents in restoring systemic blood pressure is primarily due to the antagonism of alpha-1 adrenergic receptors by TCAs. This alpha-1 adrenergic antagonism can blunt the vasoconstrictor response to exogenously administered sympathomimetic agents, reducing their ability to effectively increase blood pressure. Additionally, TCAs can inhibit the reuptake of norepinephrine, leading to a relative desensitization of adrenergic receptors, further contributing to the reduced effectiveness of sympathomimetic agents.</p> Signup and view all the answers

    Describe the potential cardiovascular adverse effects associated with Tricyclic Antidepressants (TCAs) and explain the underlying mechanisms.

    <p>Tricyclic Antidepressants (TCAs) are associated with several potentially serious cardiovascular adverse effects, including orthostatic hypotension, tachycardia, and cardiac conduction abnormalities. The orthostatic hypotension is caused by the alpha-1 adrenergic antagonism of TCAs, which can lead to vasodilation and a decrease in peripheral vascular resistance. The tachycardia is primarily due to the anticholinergic (antimuscarinic) effects of TCAs, which can increase heart rate. The cardiac conduction abnormalities, such as prolongation of the P-R interval, widening of the QRS complex, and prolongation of the QT interval, are a result of the 'Quinidine-Like effect' of TCAs, where they block sodium channels, similar to the antiarrhythmic drug quinidine. These conduction abnormalities can be life-threatening, especially in overdose situations.</p> Signup and view all the answers

    Explain the potential drug interactions between Tricyclic Antidepressants (TCAs) and sympathomimetic agents, and the recommended dosing strategy when administering these agents concurrently.

    <p>When administering sympathomimetic agents to patients recently started on a Tricyclic Antidepressant (TCA), the response may be exaggerated due to the inhibition of norepinephrine reuptake by TCAs. This can lead to a potentiation of the sympathomimetic effects, such as increased blood pressure and heart rate. However, in patients chronically treated with TCAs for more than 6 weeks, the effectiveness of conventional sympathomimetic agents may be reduced due to the alpha-1 adrenergic antagonism and desensitization of adrenergic receptors caused by TCAs. In this case, the recommended dosing strategy is to start with a lower dose of the sympathomimetic agent and titrate it slowly to the desired effect, as the patient's response may be unpredictable.</p> Signup and view all the answers

    TCAs block the reuptake of both ______ and serotonin into the presynaptic nerve terminal.

    <p>norepinephrine</p> Signup and view all the answers

    Abrupt cessation of TCA treatment may produce ______, headache, malaise, and chills.

    <p>nausea</p> Signup and view all the answers

    ______ are useful if TCAs slow AV conduction of impulses.

    <p>Atropine</p> Signup and view all the answers

    Any drug that inhibits ______ may increase the plasma exposure of TCAs.

    <p>CYP 2D6</p> Signup and view all the answers

    TCAs should ______ be given at the same time as MAOIs.

    <p>never</p> Signup and view all the answers

    What is the potential risk associated with giving TCAs and alpha-1 adrenergic antagonists together?

    <p>Increased risk of rebound hypotension</p> Signup and view all the answers

    Why should the doses of opioids and barbiturates be decreased in the presence of TCAs?

    <p>To avoid exaggerated or prolonged depressant effects</p> Signup and view all the answers

    What is a risk associated with abruptly discontinuing clonidine in patients taking TCAs?

    <p>Rebound hypertension</p> Signup and view all the answers

    Which effect may be observed in patients treated with halothane, pancuronium, and TCAs?

    <p>Potential for increased cardiac arrhythmias</p> Signup and view all the answers

    What is the effect of centrally acting anticholinergics when given to patients treated with TCAs?

    <p>Increased risk of postoperative delirium and confusion</p> Signup and view all the answers

    How does glycopyrrolate differ from atropine sulfate and scopolamine in its interaction with TCAs?

    <p>Glycopyrrolate is less likely to interact with TCAs</p> Signup and view all the answers

    What is the primary mechanism by which Tricyclic Antidepressants (TCAs) can reduce the effectiveness of conventional sympathomimetic agents in restoring systemic blood pressure in patients chronically treated with TCAs?

    <p>Adrenergic receptors are desensitized or down-regulated in patients chronically treated with TCAs</p> Signup and view all the answers

    When administering direct-acting sympathomimetic agents to patients on tricyclic antidepressants (TCAs) for more than 6 weeks, which of the following dosing strategies is recommended?

    <p>Decrease the initial dose to 1/3rd the usual dose</p> Signup and view all the answers

    Which of the following statements accurately describes the interaction between tricyclic antidepressants (TCAs) and indirect-acting sympathomimetic agents?

    <p>Indirect-acting sympathomimetics may cause an exaggerated pressor response in patients recently started on TCAs</p> Signup and view all the answers

    What is the rationale for avoiding the concomitant use of Tricyclic Antidepressants (TCAs) and Monoamine Oxidase Inhibitors (MAOIs)?

    <p>Concomitant use of TCAs and MAOIs is contraindicated due to the increased risk of hypertensive crisis</p> Signup and view all the answers

    Which of the following statements is true regarding the administration of sympathomimetic agents in patients chronically treated with tricyclic antidepressants (TCAs)?

    <p>Conventional sympathomimetics may not be effective in restoring systemic BP in patients chronically treated with TCAs</p> Signup and view all the answers

    Why should the dose of exogenous epinephrine be adjusted in patients treated with TCAs during anesthesia with a volatile anesthetic?

    <p>TCAs can potentiate the effects of epinephrine, leading to an increased risk of cardiac arrhythmias</p> Signup and view all the answers

    Which of the following best explains the 'Quinidine-Like effect' associated with Tricyclic Antidepressants (TCAs) and its clinical significance?

    <p>TCAs block sodium channels, leading to cardiac conduction abnormalities that can be life-threatening, especially in overdose situations.</p> Signup and view all the answers

    Why should the concurrent use of Tricyclic Antidepressants (TCAs) and Monoamine Oxidase Inhibitors (MAOIs) be strictly avoided?

    <p>TCAs and MAOIs have a synergistic effect on increasing norepinephrine and serotonin, leading to serotonin syndrome.</p> Signup and view all the answers

    How do Tricyclic Antidepressants (TCAs) interact with sympathomimetic agents, and what is the recommended dosing strategy when administering these agents concurrently?

    <p>TCAs enhance the effects of sympathomimetics, so the dose of the sympathomimetic should be reduced when used with TCAs.</p> Signup and view all the answers

    Which of the following anticholinergic agents is theoretically less likely to interact with Tricyclic Antidepressants (TCAs) and cause postoperative delirium and confusion?

    <p>Glycopyrrolate</p> Signup and view all the answers

    Which enzyme systems are primarily involved in the metabolism of Tricyclic Antidepressants (TCAs)?

    <p>Hepatic CYP450 enzymes</p> Signup and view all the answers

    What is the primary mechanism by which Tricyclic Antidepressants (TCAs) enhance noradrenergic and serotonergic transmission?

    <p>By inhibiting the reuptake of norepinephrine and serotonin into the presynaptic nerve terminal.</p> Signup and view all the answers

    Which type of Tricyclic Antidepressant (TCA) primarily inhibits the reuptake of norepinephrine?

    <p>Secondary amine TCAs</p> Signup and view all the answers

    What is the rationale for avoiding the concomitant use of Tricyclic Antidepressants (TCAs) and Monoamine Oxidase Inhibitors (MAOIs)?

    <p>TCAs and MAOIs have a synergistic effect on increasing norepinephrine and serotonin, leading to serotonin syndrome.</p> Signup and view all the answers

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