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Anaesthesiology
Autonomic and Cardiovascular Pharmacology
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
13 sections · 197 slides
Overview
- Scope of this topic
- Drug groups covered
- Key messages from this topic
Cholinergic Drugs
- Acetylcholine as a neurotransmitter
- Why acetylcholine itself is not a drug
- Classes of cholinergic agonist
- Structures of direct cholinergic agonists
- Comparative muscarinic actions of cholinomimetics
- Methacholine
- Bethanechol and carbamylcholine
- Pilocarpine
- Cholinesterase inhibitors: principle and uses
- Consequences of enzyme inhibition
- Reversible versus irreversible inhibition
- Chemical classes and duration of action
- Structures of clinical anticholinesterases
- Muscarinic side effects and physostigmine
- Echothiophate
Muscarinic Antagonists
- The three drugs used in anaesthesia
- Actions of muscarinic antagonists
- Presynaptic action and receptor selectivity
- Blood-brain barrier and the three antagonists
- Scopolamine in practice
- Heart rate effects and when tachycardia is dangerous
- Eye, sweating and temperature effects
- Narrow-angle glaucoma risk
- Comparative effects of muscarinic antagonists
- Inhaled muscarinic antagonists
- Structures of inhaled muscarinic antagonists
- Muscarinic antagonist toxicity
- Central anticholinergic syndrome and its antidote
- Reading the atropine dose-toxicity table
- Atropine toxicity by dose range
- Reading the antimuscarinic compounds list
- Antimuscarinic compounds linked with central anticholinergic syndrome
Fundamentals of Catecholamine Pharmacology
- Adrenergic receptors and the four beta1 effects
- Beta1 receptor signalling cascade
- Calcium handling and the failing ventricle
- Beta-adrenoceptor agonist action in myocardium
- Dose-related receptor selectivity: dopamine as the example
- Alpha1 and beta2 receptors in the vasculature
- Alpha1 signalling in vascular smooth muscle
- Alpha-adrenoceptor agonist action in vascular smooth muscle
- Net effect on arterial pressure
- Shared danger of every catecholamine
Individual Catecholamines
- Origin and cardiac actions of epinephrine
- Epinephrine in clinical use and arrhythmia risk
- Regional blood flow with epinephrine
- Epinephrine in cardiac arrest
- Venous, pulmonary, coronary and local uses
- Airway and anaphylaxis uses of epinephrine
- Epinephrine in the presence of blockers
- Norepinephrine: receptors, rate and venous effects
- Norepinephrine in shock and cardiac cautions
- Norepinephrine in the lung and kidney
- Dopamine: dose-response and its limits as a scheme
- Evidence against renal-dose dopamine
- Dopamine as an inotrope and its limits
- Dobutamine: receptor action and dose dependence
- Dobutamine: heart rate, ischaemia and the lung
- Outcome evidence against dobutamine
- Isoproterenol
- Reading the catecholamine comparison table
- Comparative effects of endogenous and synthetic catecholamines
- Selective beta2 agonists
- Fenoldopam: actions
- Fenoldopam: renal protection story and kinetics
Sympathomimetics
- How ephedrine works indirectly
- Ephedrine: profile and tachyphylaxis
- Phenylephrine
Alpha-adrenoceptor Antagonists and Agonists
- Alpha1 blockade: principle and why it fell out of use
- Unopposed beta activity during alpha1 blockade
- Phenoxybenzamine and pheochromocytoma preparation
- Order of blockade in pheochromocytoma
- Phentolamine
- Prazosin and the urological alpha1 blockers
- Clonidine: receptor action and cardiovascular profile
- Clonidine in the perioperative period
- Clonidine: analgesia, sedation and metabolic effects
- Clonidine withdrawal
- Dexmedetomidine: how it differs from clonidine
- Dexmedetomidine: clinical advantages and delirium
- Biphasic pressure response to dexmedetomidine
- Dexmedetomidine and cardiac outcome
Beta-Adrenoceptor Antagonists
- Core actions of beta-blockers
- Beta-blockers in myocardial infarction
- Established indications and perioperative role
- Chemistry and what distinguishes each beta-blocker
- Three generations of beta-blockers
- Selectivity and vascular effects of beta-blockers
- How beta-blockers lower blood pressure
- Mechanism of beta-blocker vasodilation
- Ischaemia, infarction and heart failure benefit
- Heart failure evidence and preserved ejection fraction
- Electrophysiologic effects and arrhythmia uses
- Aorta, thyroid and hypertrophic cardiomyopathy
- Topical and non-cardiac uses
- Cardiac, vascular and respiratory adverse effects
- Metabolic adverse effects
- Propranolol
- Metoprolol and atenolol
- Esmolol
- Labetalol
- Carvedilol
- Reading the beta-blocker comparison table
- Comparative effects of beta-blockers
Inodilators, Digitalis and Vasopressin
- Phosphodiesterases and their inhibition
- PDE III in heart and vessels
- How PDE III inhibitors increase contractility
- Relaxation and the inodilator concept
- Pulmonary and preload effects
- Pressure, rate and additional actions
- Oral PDE III inhibitors: a cautionary trial story
- Milrinone in practice
- Levosimendan: what a calcium sensitiser is
- Three mechanisms of levosimendan
- Levosimendan: haemodynamic effects
- Levosimendan: place in therapy and in cardiac surgery
- Reading the milrinone, levosimendan and vasopressin table
- Comparative effects of milrinone, levosimendan and vasopressin
- Digitalis: origin, place and the Treppe phenomenon
- How digitalis increases contractility
- Haemodynamic effects of digitalis
- Digitalis: arrhythmias and therapeutic margin
- Vasopressin: what it is and how V1 signals
- Vasopressin receptor subtypes
- Vasopressin in physiology and under RAAS blockade
- Vasopressin in sepsis and cardiac arrest
- Vasopressin: dangers
Nitrovasodilators and Hydralazine
- Nitrovasodilators: two kinds
- How nitric oxide relaxes vascular muscle
- Haemodynamic benefits of nitrovasodilators
- True tolerance and pseudo-tolerance
- Other adverse effects of organic nitrates
- Nitroglycerin: dose-dependent actions
- Nitroglycerin: clinical positioning
- Sodium nitroprusside: profile and reflex tachycardia
- Coronary steal with sodium nitroprusside
- Sodium nitroprusside: toxic metabolites
- Hydralazine
Calcium Channel Blockers
- Calcium channels: structure and types
- Chemical classes of calcium channel blockers
- General cardiovascular effects
- Two opposite effects on oxygen demand
- Nifedipine
- Nifedipine: strengths and a warning
- Nicardipine
- Clevidipine
- Clevidipine: further indications
- Nimodipine
- Diltiazem
- Verapamil: profile
- Verapamil in ischaemia and rhythm control
- Why verapamil is dangerous in pre-excitation
- Verapamil: further contraindications
- Reading the calcium channel blocker table
- Comparative effects of calcium channel blockers
Renin-Angiotensin System Blockade
- Renin release and what angiotensin II does
- The renin-angiotensin cascade
- Aldosterone and the net effect
- Inhibitors of the renin-angiotensin system
- ACE inhibitors: the class and its members
- ACE inhibitors: haemodynamics
- ACE inhibitors in heart failure and vascular disease
- ACE inhibitors: cough and electrolyte effects
- ACE inhibitors: angioedema and other adverse effects
- Refractory hypotension under anaesthesia
- Managing the ACE inhibitor patient before surgery
- Angiotensin receptor blockers: mechanism
- ARBs: clinical evidence
- ARBs: place, side effects and cautions
Summary and References
- Summary: the cholinergic side
- Summary: catecholamines and sympathomimetics
- Summary: the cardiovascular drug classes
- Summary: calcium channel blockers and closing points
- References
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- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition