Sterile Drug Products Used in the Anesthesia Practice Setting: Part 2 PharMEDium Lunch and Learn Series LUNCH AND LEARN Sterile Drug Products Used in the Anesthesia Practice Setting: Part 2 February 10, 2017 Featured Speaker: Julie A. Golembiewski, PharmD Clinical Associate Professor, Department of Pharmacy Practice Clinical Associate Professor of Anesthesiology University of Illinois at Chicago Colleges of Pharmacy and Medicine CE Activity Information & Accreditation ProCE, Inc. (Pharmacist and Tech CE) 1.0 contact hour Funding: This activity is self‐funded through PharMEDium. It is the policy of ProCE, Inc. to ensure balance, independence, objectivity and scientific rigor in all of its continuing education activities. Faculty must disclose to participants the existence of any significant financial interest or any other relationship with the manufacturer of any commercial product(s) discussed in an educational presentation. Dr. Golembiewski has no relevant commercial and/or financial relationships to disclose. 2 ProCE, Inc. www.ProCE.com 1 Sterile Drug Products Used in the Anesthesia Practice Setting: Part 2 PharMEDium Lunch and Learn Series Online Evaluation, Self-Assessment and CE Credit . Submission of an online self‐assessment and evaluation is the only way to obtain CE credit for this webinar . Go to www.ProCE.com/PharMEDiumRx . Print your CE Statement online . Live CE Deadline: March 10, 2017 . CPE Monitor – CE information automatically uploaded to NABP/CPE Monitor upon completion of the self‐assessment and evaluation (user must complete the “claim credit” step) Attendance Code Code will be provided at the end of today’s activity Attendance Code not needed for On‐Demand 3 Ask a Question . Submit your questions to your site manager. Questions will be answered at the end of the presentation. Your question. ? 4 ProCE, Inc. www.ProCE.com 2 Sterile Drug Products Used in the Anesthesia Practice Setting: Part 2 PharMEDium Lunch and Learn Series Resources . Visit www.ProCE.com/PharMEDiumRx to access: – Handouts – Activity information – Upcoming live webinar dates – Links to receive CE credit 5 Sterile Drug Products Used in the Anesthesia Setting – Part 2 Julie Golembiewski PharmD February 10, 2017 6 ProCE, Inc. www.ProCE.com 3 Sterile Drug Products Used in the Anesthesia Practice Setting: Part 2 PharMEDium Lunch and Learn Series THE OPERATING ROOM Anesthesia Care Provider Surgeon 7 CARDIOVASCULAR DRUGS ADRENERGIC RECEPTORS Receptor Location Response (Agonist activity) Alpha 1 Vascular smooth muscle, Contraction heart Alpha 2 Vascular smooth muscle Contraction Beta 1 Heart Increased force and rate of contraction Beta 2 Smooth muscle (lungs, Relaxation vascular) 8 ProCE, Inc. www.ProCE.com 4 Sterile Drug Products Used in the Anesthesia Practice Setting: Part 2 PharMEDium Lunch and Learn Series CLASSIFICATION OF BETA-BLOCKERS Classification Agent Non-selective Propranolol (blocks beta 1 and beta 2 decreases HR) Beta 1 selective Esmolol, metoprolol (decreases force and rate of contraction decreases HR) Alpha-blocking activity Labetolol >> beta-blocking activity (relaxes vascular smooth muscle decreases BP) 9 Beta Blockers Property Esmolol Metoprolol Pharma- Beta 1 antagonist Beta 1 antagonist cology Reduces HR and, Reduces HR and, to a much lesser to a much lesser extent, BP extent, BP Peak effect ̴ 5 minutes ̴ 10 minutes (IV) Duration (IV) 10 – 30 minutes ̴ 6 hours Usual dose 10 - 20 mg, 2 mg up to 0.5 mg/kg 10 ProCE, Inc. www.ProCE.com 5 Sterile Drug Products Used in the Anesthesia Practice Setting: Part 2 PharMEDium Lunch and Learn Series Antihypertensives Property Hydralazine Labetolol Pharmacology Direct relaxation of Alpha 1 blocker, vascular smooth nonselective beta muscle antagonist Reduces BP Reduces BP, less effect on HR than propranolol Peak effect (IV) 5 – 20 minutes 5 – 15 minutes Duration (IV) 1 – 4 hours 2 – 18 hours Clinical Reflex tachycardia Less reflex Considerations tachycardia due to beta blocker effects Usual dose 5 mg 5 – 10 mg 11 VASOPRESSORS Property Phenylephrine Norepinephrine Pharmacology Alpha 1 agonist Alpha 1 agonist (vasoconstriction) (vasoconstriction) Beta 1 and some Beta 2 effects Relaxing effect on venous resistance enhanced venous return to heart increased CO with little effect on HR BP Increased Increased HR Decreased No change or increased Contractility No change or Increased decreased Venous return Increased Decreased Cardiac output Decreased Increased Typical IV bolus 40 – 100 mcg 2 – 8 mcg dose Norepinephrine increases BP by arterial vasoconstriction and an increase or maintenance of HR, stroke volume and cardiac output 12 ProCE, Inc. www.ProCE.com 6 Sterile Drug Products Used in the Anesthesia Practice Setting: Part 2 PharMEDium Lunch and Learn Series EPHEDRINE VS. EPINEPHRINE Property Ephedrine Epinephrine Pharmacology Indirect stimulation Beta 1, beta 2 and of alpha 1 and in higher doses, beta 1 receptors alpha 1 Increases BP, HR, Increases HR, contractibility and cardiac output, BP cardiac output (less than others) bronchodilator 13 OPIOIDS 14 ProCE, Inc. www.ProCE.com 7 Sterile Drug Products Used in the Anesthesia Practice Setting: Part 2 PharMEDium Lunch and Learn Series OPIOIDS Indications Agents • Blunt hemodynamic Fentanyl, sufentanil, response to: remifentanil, morphine, hydromorphone • Laryngoscopy • Surgical stimulation • Provide analgesia Considerations • Reduce anesthetic Onset requirement Duration Route of elimination Opioids alone do NOT provide anesthesia 15 Property Morphine Hydromorphone Fentanyl (Dilaudid) Onset 5 min ≤ 5 min ≤ 2 min Peak 15 - 20 min 10 – 20 min 5 – 7 min Duration ̴ 3 – 4 hours ̴ 2 – 3 hours 30 – 60 min Renal dysfunction Active metabolite OK OK can accumulate Equianalgesic 1 mg 0.2 mg 12.5 mcg dose (plasma) (brain) Anesthesiology. 2010;112:226. 16 ProCE, Inc. www.ProCE.com 8 Sterile Drug Products Used in the Anesthesia Practice Setting: Part 2 PharMEDium Lunch and Learn Series Sufentanil – 5 – 10 times more potent than fentanyl • Usual dose: 5 – 20 mcg IV bolus – Similar onset and peak, but more rapidly eliminated than fentanyl when multiple doses (or infusion) administered Remifentanil – Slightly more potent than fentanyl • Usual dose: 12.5 – 25 mcg IV bolus – Rapidly eliminated by nonspecific plasma and tissue esterases – Shortest duration of action ( ̴ 10 minutes) • Infusion (usual range: 0.025 mcg/kg/min – 0.2 mcg/kg/min) 17 Context-Sensitive Halftime Anesthesiology. 1993;79:881–892 . 18 ProCE, Inc. www.ProCE.com 9 Sterile Drug Products Used in the Anesthesia Practice Setting: Part 2 PharMEDium Lunch and Learn Series OPIOID ADVERSE EFFECTS • Nausea, vomiting, constipation • Sedation, dizziness • Itching • Bradycardia (intra-op boluses) • Apnea, respiratory depression 19 LOCAL ANESTHETICS 20 ProCE, Inc. www.ProCE.com 10 Sterile Drug Products Used in the Anesthesia Practice Setting: Part 2 PharMEDium Lunch and Learn Series Local Anesthetics Agent Onset Duration Max Dose * Comments Chloroprocaine Fastest Short 800 (1,000) Epidural Lidocaine Rapid Intermediate 300 (500) Most frequently used Mepivacaine Moderate Intermediate 300 (500) Nerve block, epidural Bupivacaine Slow Long ** 175 (225) Local infiltration, (up to 12 nerve block, hrs) epidural, spinal Bupivacaine Slow Longest 266 Local infiltration liposome (up to 72 only hrs) Ropivacaine Slow Long ** 200 (200) Local infiltration, (up to 12 nerve block, hrs) epidural * In milligrams; epinephrine containing solution in parenthesis ** May be given as a continuous infusion for local infiltration, epidural, peripheral nerve block 21 SPINAL AND EPIDURAL ANESTHESIA Spinal needle 22 ProCE, Inc. www.ProCE.com 11 Sterile Drug Products Used in the Anesthesia Practice Setting: Part 2 PharMEDium Lunch and Learn Series NERVE BLOCK ANESTHESIA Femoral nerve block Sciatic nerve block Source: http://www.privatehealth.co.uk/private-operations/Anaesthesia/femoral-nerve-block/ http://www.privatehealth.co.uk/private-operations/Anaesthesia/sciatic-nerve-block/ 23 LOCAL INFILTRATION (SURGEON) Source: 24 ProCE, Inc. www.ProCE.com 12 Sterile Drug Products Used in the Anesthesia Practice Setting: Part 2 PharMEDium Lunch and Learn Series Local Anesthetic Infusions 25 PERIOPERATIVE ROUTES OF ADMINISTRATION OF LOCAL ANESTHETICS Surgeon Anesthesia Topical* Spinal Subcutaneous, deep tissue Epidural Transversus Intravenous abdominal plane* (lidocaine only) Tumescent Peripheral technique nerve block Intra- or periarticular * Surgeon or Anesthesia 26 ProCE, Inc. www.ProCE.com 13 Sterile Drug Products Used in the Anesthesia Practice Setting: Part 2 PharMEDium Lunch and Learn Series PERIOPERATIVELidocaine ROUTES OF ADMINISTRATION FastOF LOCAL onset, ANESTHETICS Topical Short duration (1 - 3 hrs) Spinal Subcutaneous, deep tissue Epidural Transversus Intravenous abdominal plane Tumescent Peripheral technique nerve block Intra- or periarticular 27 BupivacainePERIOPERATIVE or Ropivacaine ROUTES OF ADMINISTRATION OF LOCAL ANESTHETICS Slow onset, long duration (4 – 18 hrs) Topical Spinal Subcutaneous, (bupivacaine only) deep tissue Epidural Transversus Intravenous abdominal plane Tumescent Peripheral technique nerve block Intra- or periarticular 28 ProCE, Inc. www.ProCE.com 14 Sterile Drug Products Used in the Anesthesia Practice Setting: Part 2 PharMEDium Lunch and Learn Series PERIOPERATIVE ROUTES OF ADMINISTRATIONLiposome Bupivacaine OF LOCAL ANESTHETICSFast onset, long duration (up to 72 hrs) Topical Spinal Subcutaneous, (bupivacaine only) deep tissue Epidural Transversus Intravenous abdominal plane Tumescent Peripheral technique