Transcript New Anesthesia Drugs Already here or on the Horizion

New Anesthesia Drugs
Already here or on the Horizon
Major Peter D. Strube
CRNA MSNA APNP ARNP
We must start to think differently.
We can no long say “When I was in my training”
Things are in evolution and only getting faster and faster!
NBCRNA??
Facebook? Google? Twitter?
Dedicated to:
Thomas G Healey, RN, CRNA, MA
St Mary’ s University
Died January 5, 2014
Basic Rules:
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Suxx does not suck..
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Nobody has ever had a allergic reaction to a ET Tube!!
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Nobody gets sued for leaving it in to long
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Blue is the not the color of Peds!
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Green Gas is Good!
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Atropine and Suxx are CHEAP!
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If your thinking about intubating should have already done it!
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New Term: Pre-Mature Extubation!
Think outside the BOX—
Think Differently!
ZOFRAN EXAMPLE
Old Drugs, New Ways
New Drugs, Old Battles!
Why bother with the
future?
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“The future belongs to the unreasonable ones, the ones who look
forward not backward, who are certain only of uncertainty, and who
have the ability and the confidence to think completely differently.”
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Charles Handy quoting Bernard Shaw
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Progressives are main stream only ahead of their time!
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The point is not to predict the future but to prepare for it and to
shape it
Keep up on Current Information:
►Codeine----FDA
►Keep
alert…..
a open mind…
Acute Perioperative Pain
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Perioperative pain
 Approximately 46 million inpatient procedures and 35 million
outpatient surgeries were performed in the US in 2006
 Despite new treatment standards, guidelines, and educational
efforts, acute postoperative pain continues to be undertreated,
with up to 75% of patients in the US still failing to receive
adequate postoperative pain relief
 With the advent of Hospital Consumer Assessment of
Healthcare Providers and Systems (HCAHPS) surveys, patients
are now able to make decisions on hospitals based on quality of
care, including quality of pain management
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Economic Impact – for each incident of
nausea/vomiting that is avoided:
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Avoid resource utilization costs: Patients who vomit spend an
average of 43 minutes longer in the PACU at a cost of $85 for nausea
and $138 for vomiting.
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Save the cost of rescue treatment: $283 (minimum) to treat
patients who experience PONV
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For surgical centers: PONV delays may result in an ambulance
transfer to a hospital costing $300 - $900 and result in an admission
costing $1,200 to more than $2,400 per day.
Comfort Zone
► Most
zone
of us practice our art in the comfort
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and different ideas tend to pull people
from the comfort zone to the scare zone
► Try
new things
► Enhance your patient outcomes
Patient Satisfaction Scores: American Health Care
Affordability Act.
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A random sample of patients discharged from hospitals across the country are
surveyed and asked questions about their feelings and perceptions about their
hospital stay. This measure combines hospital performance on questions that
asked patients their levels of satisfaction with some of the following elements of
their stay:
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How well nurses communicated with patients
How well doctors communicated with patients
How responsive hospital staff were to patients’ needs
How well caregivers managed patients’ pain
How well caregivers explained patients’ medications to them
How clean and quiet the hospital was
How well caregivers explained the steps patients and families need to
take to care for themselves outside of the hospital (i.e., discharge
instructions)
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The survey also asks patients to give an overall satisfaction rating to their hospital
stay.
Fospropofol (Lusedra)
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Approved by the FDA on 12/12/08 a pro-drug of propofol
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Same mechanism of action; except has a slow, smooth and predictable rise in concentration
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By; Definition: this is a sedative-hypnotic aqueous agent indicated for
monitored anesthesia care (MAC) sedation in adult patients undergoing
diagnostic or therapeutic procedures.
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NOT FOR GENERAL
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This will and has already raised some concern—FDA states that only
those trained in delivering anesthesia should use
this drug. What about the ago old question??
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What about using this in GI clinic
Fospropofol (Lusedra)
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Standard monitoring
IV dosing adults: 6.5mg/kg – followed by supplemental dosing of
1.6mg/kg as needed
Initial dose should not exceed 16.5 ml (35mg/cc)
90 kg x 16.5 = 585mg
Supplemental doses should not exceed 4ml; each additional doses
should only be given when needed and no more frequent than every 4
minutes
Dose range 60-90 kg
Not for Kids
Greater than 65 years of age give 75% of dose
For every 1.86mg administered one mg of propofol is created
What is special: earlier “clear headed”
Fospropofol (Lusedra)
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Expensive
Side effects:
Respiratory Depression 6%; Hypoxemia 5%; Hypotension 5%
EXPENSIVE
Not comparatively better than propofol and versed
Not compatible with versed or Demerol
Need to flush line after use
Greater than 20% experience paresthesia and cough
Paresthesia by their definition included: burning, tingling and stinging
This was manifested in the perineal region:: why phosphate preservative
Remimazolam
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Analogue of Midazolam that utilizes the ester design. Broken down by
nonspecific ester hydrolysis
Designed for out patient procedures as well as EGD/C-Scope area
Linear Clearance superior to Versed
Better sedation with less side effects of Versed
 respiratory and cardiac events
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6mg loading Dose followed by 3 mg maintenance doses
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Crazy but initial studies have not change in ventilation or oxygenation with
remidmazolam with NO supplemental oxygen applied……….
Etomidate --MOC
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Methoxycarbonyl-etomidate (MOC-etomidate), a new compound derived from
the anesthetic etomidate, is as fast-acting and provides the same
hemodynamic stability as its parent drug, but does not cause dangerous
adrenal gland suppression as etomidate can
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In the human liver cells, the researchers found that the MOC-etomidate had an
in-vitro half-life of 4.4 minutes versus more than 40 minutes for etomidate,
and produced carboxylic acid as its only detectable metabolite
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MOC-etomidate is an etomidate analogue that retains etomidate's
important favorable pharmacological properties. However, it is rapidly
metabolized, ultra-short acting, and does not produce prolonged
adrenocortical suppression following bolus administration
Carboetomidate
► Analogue
of etomidate
► When compared to MOC it has slow onset
and difficult to formulate.
► ???
Benefit ???
Emend (Aprepitant) PDNV
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A new class of antiemetics is born -- NK-1 receptor antagonists
Does not interfere with other antiemetics
No dosage adjustments for hepatic or renal compromise
Does not effect QT segments
Use in caution with CYP3A4 (warfarin) drugs; this is typically related to
a three day course in chemo-related treatments
Decreases efficacy of hormonal contraceptives
Anesthesia is a single dose; 40-80mgs
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Expensive single 80mg dose is $125
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Emend (Aprepitant)
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This is a additional adjunct treatment to those refractory to PONV
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Most side effects are related to prolonged and high doses with little
evidence that any effects are related to a single anesthesia dose
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Top adverse experiences in patients with general anesthesia were;
Anemia, bradycardia, flatulence, hypotension, pruritus, pyrexia
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Expensive ; Expensive; Expensive; Expensive
Marinol
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MARINOL should not be used if you are allergic to dronabinol
or any of its ingredients, including marijuana and sesame oil
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Most patients respond to 5 mg three or four times daily. Dosage
may be escalated during a chemotherapy cycle or at subsequent
cycles, based upon initial results. Therapy should be initiated at
the lowest recommended dosage and titrated to clinical response.
Administration of Marinol Capsules with phenothiazines, such as
prochlorperazine, has resulted in improved efficacy as compared
to either drug alone, without additional toxicity.
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Marinol has been shown to provide increased pain relief when
taken in combination with opioid pain relievers, according to
ClinicalTrials.gov. The active ingredient in Marinol, THC, is
believed to bind with pain receptors to reduce the transmission of
pain through the spinal cord and brain
Cleviprex
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New Calcium Channel blocker
?? Dose it’s problems outweigh it’s benefits
Could be a key agent for emergency hypertensive crisis
Hypertensive therapy when oral agents not feasible
Has a rapid onset and 1-2 minute half-life (15 minutes to total
elimination)
Could find a spot with cardiac surgery and cardiac patients(?)
Maybe Neurosurgery -- Emergency room
Vascular selective -- acts specifically on vascular smooth muscle to
reduce arterial BP (after load) without inducing myocardial depression
Cleviprex
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Positives:
Non weight based dosing
Dose-dependent BP lowering response
No dose adjustment for renal or hepatic dysfunction
Ready to use vials
Can be administered via peripheral line
Dosing: 1-2 mg/hr with a double very 90 seconds until goal BP
Max dose 16mg/hr
Cleviprex
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Downside???
Lipid based (no more than 1000 mls/24 hours period)
$$ 4 hours of use then discard
Can’t be administered with anything else (dedicated line)
Contraindicated with soy, egg allergy
Contraindicated with hyper lipidemia; lipoid nephrois, pancreatitis,
aortic stenosis
Negative inotropic effects—contraindicated in heart failure
(but is suppose to not cause any myocardial depression)
Not for use with beta blocker withdrawal
2% of patients develop HA/N&V
Store refrigerated (not easy access)
Photosensitive
New Pain Drugs
► Ofirmev
► Caldolor
► Sufentanil
Patch
► Nucynta
► Remoxy
► Mexiletine
► Antidote:
Entereg
 (almivopam)
Multimodal Approach to Acute Pain Management
STEP 3
STEP 2
and
Higher doses of opioids
Severe Pain
STEP 2
STEP 1
and
Low doses of opioids
Moderate Pain
STEP 1
Mild Pain
Acetaminophen, NSAIDs, or COXIBs
and
Local/regional anesthesia
Modified from Crews et al., 20021
1. Crews JC. JAMA. 2002;288:629-632. 2. World Health Organization. Pain relief ladder. http://www.who.int. Accessed November 21, 2011. 3. Ventafridda V, et al. Cancer. 1987;59:850-856. 4. ASA Task Force.
Anesthesiology. 2004;100:1573-1581.
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OFIRMEV $10.00/1000mg
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IV acetaminophen injection: Cadence Pharm
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Minimum dosing interval is every 4 hours
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No change when going from IV to Oral
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Administer over 15 min…..well….?????
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www.ofirmev.com
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Do not exceed max daily doses.. Adult is 4 grams per day
Pediatric is dosed at 15mg/kg with max of 75 mg/kg/day
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CHEAPPPPPPPP
OFIRMEV
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Liver issues is big
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Contraindicated in patients with liver failure/hepatic injury or with known
hypersensitivity to acetaminophen…
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What about ETOH?
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Common side effects are: N/V; HA: insomnia; constipation, pruritus and
agitation and atelectasis
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Using this drug may mask post surgical fever when used for post-operative
pain.
Ibuprofen-Caldolor $10
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Think about Ketorolac.. Actions and side effects
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Big differences… Less action on Cox 1 and more Cox 2 action..
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What does this mean? Less bleeding.. More pain control can give anytime
during the surgery… better now that we can give per--op
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400mg/4ml or 800mg/8ml
Dilute and administer over 30 minutes
400mg-800mg Over 30 min repeat every 6 hours PRN*
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Fluids Fluids Fluids “ well hydrated prior to use”
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Sprix-Nasal Ketorolac
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Short Term use… Up to five days.
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Some risk as IV or IM Ketorolac
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Dose: 31.5mg or 15.75 mg each spray per nostril
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Max daily dose is 63 mg
Sufentanil $3.52/50mcg
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5 - 10X more potent than fentanyl
Sufentanil 0.0035 mg = fentanyl 0.05 mg
Safe therapeutic index: 25,211
Dose: .025 - 30 µg/kg
Analgesic dose: 0.1 - 0.4 µg/kg IV
Maintenance dose: 1µg/kg followed by 0.25-0.5 µg/kg/hr
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High dose: 10 - 30 µg/kg
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► New
PATCH coming out from Durrect
Pharm….
Fentanyl Patch
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Transdermal Patch
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Technology changing for delivery
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Dose starting at 25 mcg/hr
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On Demand? : Fentanyl iontophoretic transdermal
system provides a 40 mcg dose of fentanyl per
activation on-demand
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Other fentanyl thoughts:
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BUCCAL TABLET; BUCCAL SOLUBLE FILM; SUBLINGUAL
TABLETS; NASAL SPRAY; SUBLINGUAL SPRAY
Nucynta--PO
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Tapentadol is used to treat moderate to severe pain that is expected to last
for a short time
Tapentadol is a centrally-acting synthetic analgesic; the exact mechanism of
action is unknown.
Although the clinical relevance is unclear, preclinical animal studies have
shown that tapentadol is a:
— Mu-opioid agonist.
— Norepinephrine reuptake inhibitor
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Contraindicated in patients with significant respiratory depression, acute or
severe bronchial asthma or hypercapnia or paralytic ileus.
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Contraindicated in patients currently using or within 14 days of using
monoamine oxidase inhibitors (MAOIs) due to potential additive effects on
norepinephrine levels, which may result in adverse cardiovascular events
Nucynta--PO
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Patients receiving other mu-opioid agonist analgesics, general anesthetics,
phenothiazines, other tranquilizers, sedatives, hypnotics, or other CNS
depressants (including alcohol) concomitantly with NUCYNTA may exhibit
additive CNS depression.
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Interactive effects resulting in respiratory depression, hypotension, profound
sedation, coma or death may result if these drugs are taken in combination
with NUCYNTA. When such combined therapy is contemplated, a dose
reduction of one or both agents should be considered.
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Opioid analgesics can raise cerebrospinal fluid pressure as a result of
respiratory depression with carbon dioxide retention
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The most common adverse events are nausea, dizziness, vomiting,
somnolence and headache
Remoxy
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Remoxy is an oral, long-acting oxycodone gelatin capsule
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Remoxy is intended to meet the needs of physicians who
appropriately prescribe opioid painkillers and who seek to
minimize risks of drug diversion, abuse or accidental
patient misuse. Remoxy resists injection or snorting.
Published data also show that freezing, crushing or
submerging Remoxy in high-proof alcohol for hours at a
time releases just a fraction of oxycodone at time points
when abusers presumably expect to get high
Introducing: Entereg
(almivopam)
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ENTEREG achieves selective GI opioid antagonism without reversing the central
analgesic effects of µ-opioid antagonists
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ENTEREG Capsules are contraindicated in patients who have taken therapeutic doses of
opioids for more than 7 consecutive days immediately prior to taking ENTEREG
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Most common adverse reactions in patients treated with ENTEREG (incidence ≥3% with
ENTEREG and at least 1% greater than placebo) undergoing bowel resection were
anemia, dyspepsia, hypokalemia, back pain, and urinary retention
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Not recommended for use in patients with severe hepatic impairment, end-stage renal
disease, or in patients undergoing surgery for correction of complete bowel obstruction
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Only for Hospital use
Palonosetron (Aloxi) PDNV
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A new 5HT-3 receptor antagonist
Remember: this group of drugs compete with serotonin to block
binding at the serotonin receptor binding site
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When the binding site is blocked the ion channel on the receptor closes
and calcium influx is stopped, blocking signals to the brain that trigger
nausea and vomiting
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What is special about this 5HT-3???
Aloxi binds with both the serotonin site but also a allosteric binding
site; this action increases the overall affinity for aloxi by triggering a
conformational change. This change also causes a receptor
internalization and induces a prolonged inhibition of serotonin binding
to the cell surface receptors.
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Aloxi
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What is cool about it?? 40 hour plasma half-life
Small single dose --- 0.075 mg single dose
Easy to remember dose timing -- before induction of anesthesia in
preop over 10 seconds ( will cover why shortly)
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NO information for Peds or OB
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Warnings::::: do not mix with other drugs
Flush line before and after admin ?? PKA – weak acid vs. weak base
Risks: 5% QT prolongations; bradycardia 4%; Headache3%
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Headache (remember imitrex)
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Aloxi
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No real elimination issues
Eliminated via renal and some metabolic pathways
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Dose: each 1.5 ml vial contains 0.075 mg of aloxi and 83 mg of
mannitol (and buffers)
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Contraindications: hypersensitivity
Contraindications: ?? Several cardiac disease ???
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Nicotine??
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Nicotine agonists
 Nicotine nasal spray dose of 3 mg versus NS nasal spray placebo
during closure
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Does not work on smokers as they seem to be desensitized to nicotine
from chronic use
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Nicotine patch is even more effective than nasal spray with VAS scores
in
Capsaicin
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Is a new Receptor Born? TRPV 1
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Selectively stimulates unmyleninated C fibers afferent neurons and cause
release of substance P
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This continued release leads to depletion of substance P and decrease in
pain
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Patch and PO
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PO is chili-peppers or Herbal 40,000 H.U.
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PO is also in pure form under trials
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Could be a benefit? Heart burn? Burning senstaion?
Voluven
Is Hespan a thing of the past?
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A new colloid – used to treat hypovolemia
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What is the benefit?? What about hespan?
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Remember hespan has a max dose of 20cc/kg to a max of 1000cc’s
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Voluven has a max dose of 50cc/kg
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Initial dose should be 10-20cc (not per kg) and observe for signs of a
reaction
Voluven
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Contraindications:
Hypersensitivity; fluid overload; CHF; renal failure; dialysis;
hypernatremia; hyperchloremia; intracranial bleeding
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Watch for dilution of blood products
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Adjust for renal and hepatic patients
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Number one side effects is pruritus
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Watch for anaphylactoid and hypersensitive reaction
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Exparel
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EXPAREL is a local analgesic that utilizes bupivacaine in
combination with the proven product delivery platform,
DepoFoam®. A single intraoperative injection given at the
close of surgery delivers postsurgical pain control with reduced
opioid requirements for up to 72 hours
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Following its release from the DepoFoam® particles, the rate
of systemic absorption of bupivacaine is dependent upon the
total dose of drug administered, the route of administration, and
the vascularity of the administration site
a pivotal soft tissue trial of EXPAREL versus placebo, patients
experienced a 30% reduction in cumulative pain scores and a
45% reduction in opioid consumption
Exparel
Posidur
► New
product just like Exparel
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Clear…. Could this be trouble?
Becareful… Do you read!
Gantacurium
► Is this a new Generation being born of NMB?
► Based on amino acid pathway--olefinic
► This drug is chemically degraded by rapid adduction
to L-cysteine and removes Chlorine
► These two routes make it unavailable to bind to
acetycholine receptor
► Does not require Liver, Kidneys, Tempature or pH
► Two exciting analogs…
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has always been a search for the new Suxx…..
Gantacurium
► Dose:
0.5 mg/kg
► Fast acting with short duration
► Exciting
► Key
new group of drugs!
is: NO histamine release!
CW002
► Same
► This
pathway as Gantacurium!
compound Lacks Chlorine
► Dose:
0.15mg/kg
► Fast acting Intermediate duration
► Key
is: NO histamine release!
CW 011
► This
is the baby of this group…
► Lacks Chloride so slower to break down
► Dose:
0.10 mg/kg
► Fast acting more intermediate duration
► Key
is: NO histamine release!
Sugammadex--Bridion
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Forms a very tight water soluble complex with steroidal NDMR
i.e. ROC > VEC > PANC
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It is biologically inactive, does not bind to plasma proteins
Does not rely on renal excretion
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WE have always miss-used muscle relaxants (first reported 1979)
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IV administration results in rapid removal of free drug from the plasma.
This action creates a concentration gradient favoring the movement of
the NDMR molecules from the NMJ back into the plasma, where they
are encapsulated by free sugammadex molecules.
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Sugammadex
Does not affect SUXX or benzylisoquinoliniums;
► If after using sugammadex and paralysis needs to be achieved consider using
these drugs
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SIDE EFFECTS: hypotension; coughing (was from a study when given to awake
patients) vomiting, nausea, dry mouth, decreased temperature
Expensive
► Rumor has it;;; it will be packaged with ROC
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Is traditional Neuromuscular function monitoring needed?
Sugammadex
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Dose examples: ROC 1.2mg.kg adminstered and three minutes later
16mg/kg of sugammadex given, this provides faster onset/offset profile
than suxx
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Remember FRC
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Will this change the face of anesthesia??
Sugammadex (Bridion)
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1st/only selective relaxant binding agent (SRBA)
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Rapidly and predictably reverse any depth of muscle relaxation inducted by
Roc/Vec
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Modified gamma-cyclodextrin with a lipophilic core and hydrophilic
periphery
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Encapsulates the Roc/Vec molecules—negatively charged extensions
electrostatically bind to the positively charged ammonium group
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Benefits of NMB reversal without other undesirable autonomic cholinergic
effects of anticholinesterases.
Sugammadex
L-Cysteine
► Dissolved
in concentration of 200mg/ml
► Antidote for New class of Muslce relaxants
 Olefinic isoquinolinium Diester NMB
 Takes advantage of this pathway
 Naturally occuring amino acid
 Only works with new group of NMB’s
L-Cysteine
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Human Studies: IV administration of exogenous L-Cysteine induced faster recovery.
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Dose in Studies: 5-50mg/kg
 (average dose is 10mg/kg)
Compared to Edrophonium reversal with atropine. Did not need to give antimusarinic
agent.
Reversed in 1 minute
There are risks…High doses: (added to TPN) but 1-1.5 grams/kg can cause neuro defects
reported in infants
What about? What in Common?
Xenon
A age old treatment has always been on the side lines
► Inert gas
► 1939 first experiments were for the US Navy
► Rediscovered in 1990
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Xenon has the ability to interact with cell proteins and cell membranes; this
action is presumably responsible for its anesthetic potency
► Xenon also inhibits plasma membrane calcium pump, which may be
responsible for an increase in neuronal calcium and altered excitability
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Xenon seems to inhibit nociceptive responsiveness of the spinal dorsal horn
neurons and effect that may be mediated by inhibition of NMDA receptors
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Basically we are not 100% sure how it works
XENON
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MAC 0.71
Fast on fast off
No apparent effect on the gut (mesenteric vascular resistance)
Minimal effects on cardiovascular tissues
Very rare NOBLE gas
Recovered from the atmosphere through a process called air
liquification
This rarity leads to expense $10/Liter (100 x more than N20)
Triple the cost of SEVO and ISO
To be useful needs to be administered via a rebreathing circuit via the
lowest possible gas flows
XENON
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The cost differences could be adjusted and would become
progressively smaller the longer the duration of anesthesia. The rate
of xenon consumption declines overtime as the body tissues become
saturated in a closed rebreathing system
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Europe just introduced a new MACHINE that should make this
affordable in the coming years
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Nitrogen must be washed out first (5-minutes)
Hypnotic effects achieved in 1.5/min reaching desired effects in 8 min
Less diffusion hypoxia
Does not prolong NDMB
Non-flammable and non explosive
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XENON
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Go Green:
The lifetime of N20 in the atmosphere is 120 years and has actually
been proven to contribute to global warming
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Xenon is being part of the atmosphere and manufactured from
liquefied air, doesn’t add to pollution – it is simply back to where it
started
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If all yearly production (6 million liters) were used only for anesthesia
only 400,000 anesthetics could be performed
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We need to create a effective way to recycle this
Tham
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Are the days of treating trauma acidosis with bicarb over?
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Tham supplements the buffering capacity of the blood bicarbonate
system, accepting a proton, generating bicarbonate and decreasing the
partial pressure of carbon dioxide in arterial blood
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It rapidly distributes through the extra cellular space and slowly
penetrates the intracellular space, except for erythrocytes and
hepatocytes and it is excreted by the kidney
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Key; THAM works continuously and maintains its buffering power in
the presence of Hypothermia
Tham
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Tham rapidly restores pH and acid base regulation in acidaemia caused
by carbon dioxide retention or metabolic acid accumulation, which
have the potential to impair organ function
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In large dose it may cause respiratory depression and hypoglycemia
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Dosage: Loading dose of THAM acetate 0.3 mol/l in the treatment of
acidaemia
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Example: ml of 0.3mol/L soln = KG x base deficit
Max dose is 15 mmol/kg or 3.5L of a 0.3mol/l soln in a 70 kg patient
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70kg X -9.1 = 637cc
THAM
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In early treatment THAM can save lives by maintain normal pH
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This treatment keeps the homeostatic mechanisms of acid-base
regulation to assume normal function
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THAM has been used in the periphery for years and small doses
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The war in IRAQ and Afghanistan have pushed it’s use to be the major
treatment in trauma
Tranexamic Acid
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New to Ortho World
A competitive inhibitor of plasminogen, and in high
concentrations a non-competitive inhibitor of plasmin
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Dose for ortho total joints with no renal or cardiac issues is
simple… 1000mg…. Not weight based for these cases
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Patients feel better…..
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Less transfusions -- reported %50
Indocyanine Green
Old drug; so not really new; but a new use that we should be aware of
► For those of that are old we remember this drug in cardiac outputs before the
thermo dilution.
► Used in Neurosurgery
► Ophthalmologic clinics for retinal imaging
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In Neurosurgery it allows the surgeon to record flow images
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Dose: 6.25mg (single ampoule is 12.5mg in 5cc) so half a amp
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Iodine based so you may get a reaction with patients allergic to shellfish and
iodine.
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Mild pulse dosimeter interference
Wait for surgeons signal
Administer rapid IV bolus with flush
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Blood Substitutes
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Not really? Should really be called oxygen transport substitutes
Examples: Hemopure, Oxygent, Polyheme and Perftoran
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They are either perfluocarbon or hemoglobin based
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Most products vary in the level of clinical phase trials
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US military experimenting with blood substitutes as well as dried blood
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Israel military in conjunction with core dynamics has a done all the
initial research on freezed dried blood; your own blood stored for you
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Corneal Abrasions During General Anesthesia
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The cornea is the clear, dome-shaped outer area of the eye. It lies in front of the colored part of the
eye (iris) and the black hole in the iris (pupil). The outermost layer of the eyeball consists of the
cornea and the white part of the eye (sclera). A corneal abrasion is basically a superficial cut or
scrape on the cornea. A corneal abrasion is not as serious as a corneal ulcer, which is generally
deeper and more severe than an abrasion
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To diagnose a corneal abrasion, a topical anesthetic with a yellow dye called flourescein is placed into
the eye. Under blue cobalt light, the part of the cornea abraded will be stained by the dye and is
easily seen by the examiner. The area and depth of the abrasion can be easily seen under a special
microscope called a slit lamp biomicroscope. If a microscope is not available, then a blue light called
a Burton lamp may be used
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Topical nonsteroidal anti-inflammatory drugs (NSAIDs) such as diclofenac (Voltaren) and ketorolac
(Acular) are modestly useful in reducing pain from corneal abrasions
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If antibiotics are used, ointment (e.g., bacitracin [AK-Tracin], erythromycin, gentamycin [Garamycin])
is more lubricating than drops and is considered first-line treatment. In patients who wear contact
lenses, an antipseudomonal antibiotic (e.g., ciprofloxacin [Ciloxan], gentamycin, ofloxacin [Ocuflox])
should be used, and contact lens use should be discontinued. Clinical trial data are lacking, but it is
recommended that contact lenses be avoided until the abrasion is healed and the antibiotic course
completed.
Others that might impact Anesthesi
► JM-1232
New hynotic nonbenzo from Japan
► PF0-713 Variant of Propofol
► AZD-3043 Nonbarb hypnotic
Thoughts?
What about using old Drugs for something
New?
Could we see changes this way?
Should we pay attention to the changing
world?
Lidocaine
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Amide local anesthetic; acting on sodium channels. Also works on
dorsal horn neurons, muscarinic/dopaminergic/k/nicotinic and multiple
other tissue receptors.
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Reduces neural response to pain by blockade of inhibition of nerve
conduction. This is achieved through suppression of conduction of
myelinated A-delta and unmyelinated C nerve fibers.
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Lidocaine is shown to suppress spinal cord sensitization, and inhibit
spinal visceromotor neurons.
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Lidocaine is an anti-inflammatory that improves outcomes related to
post op pain.
Lidocaine Infusions
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Half-life 8 minutes
90% hepatic metabolism P450-1A2—renal 10%
Bolus 1-2.5 mg/kg Load
Infusion 1-3 mg/min
Stop infusion 60 minutes post skin closure
Opioid Sparing effect
Improved pain scores—some studies showed this effect for 48-72 hrs
Return to faster bowel function
Decreased length of stay
Dexamethasone—Regional??
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Steroids are useful as adjuvant therapy for pain
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Steroids can directly reduce pain in concert with opioid
use and allow for a reduction in dose
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Steroids reduce pain by inhibiting prostaglandin synthesis
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Steroids have been shown to reduce spontaneous
discharge in an injured nerve, which reduces neuropathic
pain.
KETOFOL
THEORY OF KETOFOL:
PRO ARGUMENT:
Ketamine preserves respiratory function -> counterbalance the respiratory depression associated with propofol.
Ketofol reduces required amount of propofol -> less respiratory depression.
Less hypotensive episodes with ketofol versus propofol alone (ketamine preserves BP).
Ketofol leads to a reduction in opioid requirements.
Ketofol has fewer side effects (than ketamine)
CON ARGUMENT:Ketofol is nothing more than propofol sedation where fentanyl analgesia is replaced with
dissociative ketamine.
Ketofol does not reduce respiratory depression or is a superior sedative as compared to either drug when used
alone.
Remifol???
Questions
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