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The Peripheral Nervous Systems: Autonomic and Somatic Nervous System Pharmacology- Part 3
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1.A patient presents with an anaphylactic reaction following a wasp What i s the drug of choice for treating the multiple cardiovascular and pulmonary problems that, i f not promptly corrected, could lead to the patient’s death?
2. Cardiac output improves when dobutamine i s given, by IV infusion, to a 60-year-old man with acute, symptomatic heart By what adrenergic receptor-mediated actions, and through which ultimate effects of i t, do therapeutic doses of dobutamine mainly raise cardiac output?
- α-adrenergic agonist
- α-adrenergic antagonist
- β1-adrenergic agonist
- β1-adrenergic antagonist.
- Mixed α and β agonist
- Mixed α and β antagonist
3. We are using novel in vi tro methods to investigate the fate and post-synaptic actions of norepinephrine, released upon an action potential generated in an adrenergic An action potential i s generated and the postsynaptic effector briefly responds. Almost instantaneously the response i s over. What process mainly accounted for the brevity of the response, and termination of the released NE’s actions?
- Metabolism by enzyme(s) located near the postsynaptic receptor(s) and/or in the synaptic cleft
- Reuptake into the nerve ending
- Metabolism by catechol-O-methyltransferase (COMT)
- Degradation by mitochondrial monoamine oxidase (MAO)
- Conversion to a “false neurotransmitter” in the nerve ending
4. We are contemplating administration of a nonselective β-adrenergic blocker to a In which of the following conditions i s thisconsidered generally acceptable, appropriate, and safe?
- Angina, vasospastic (“variant”; Prinzmetal)
- Diabetes mellitus, insulin-dependent and poorly controlled
- Heart block (second degree or greater)
- Hyperthyroidism, symptomatic and acute
- Severe congestive heart failure
5. A patient presents in the Emergency Department in great distress and with the following s igns and symptoms:
Which drug most l ikely caused these s igns and symptoms?
- AChE inhibitor
- α-adrenergic blocker
- β-adrenergic blocker
- Parasympathomimetic (muscarinic agonist)
- Peripherally acting (neuronal) catecholamine depletor
7. Acebutolol and pindolol are classified as β-adrenergic blockers with intrinsic sympathomimetic activity (ISA). In a practical sense, what does ISA mean apropos the actions of these two drugs?
- Are partial agonists (mixed agonist/antagonists)
- Cause norepinephrine and epinephrine release
- Induce catecholamine synthesis
- Potentiate the actions of norepinephrine on α-adrenergic receptors
- Useful when cardiac positive inotropic and chronotropic effects are wanted
8. A 10-year-old boy i s diagnosed with Attention Deficit/Attention Deficit-Hyperactivity disorder (ADD/ADHD). Which drug i s most l ikely to prove effective for relieving the boy’s main symptoms?
Questions 8 to 14
The table below shows the perioperative medication administration record (MAR) for an otherwise healthy 50-year-old woman. (To make things interesting—and write some additional questions—I’ll deviate from her actual MAR and ask a few questions about relevant but hypothetical scenarios.) She i s a nonsmoker, consumes no more than four glasses of wine per week, and has no personal or familial ri sk factors for heart disease or diabetes. She i s taking no other medications. This patient had two scheduled (nonemergent) laparoscopic abdominal surgeries done back-to-back in the OR. The fi rst was to remove an adnexal (ovary and/or fallopian tube) mass that had been present for a couple of years and grew s lowly and i rregularly over a couple of years, and to get a pathology report to see whether i t i s cancerous. Her pathology affected one ovary. Once the ovary was removed a different surgeon performed a second procedure, through the same belly incisions, to alleviate some inconvenient urinary bladder problems.
Her MAR i s very typical of what you would find for many otherwise healthy patients undergoing the same or s imilar surgeries. The fi rst drug l i sted, midazolam, was given in the preop area right before she was transported to the OR (and I will address i ts use in the CNS questions; the abbreviation IVP next to midazolam means “IV push,” that i s , a bolus injection). All the rest were given in the OR by a CRNA (certified registered nurse anesthetist).
Use the table’s data, or what you should be able to infer from i t, to answer the next seven questions.
8. Ephedrine was the fi rst drug administered after anesthesia premedication and induction with several parenteral What best describes ephedrine’s mechanism of action?
- Directly, selectively, strongly stimulates α-adrenergic receptors in the peripheral vasculature
- Enhances norepinephrine release by blocking presynaptic α-receptors
- Increases norepinephrine synthesis
- Inhibits norepinephrine’s intraneuronal metabolic inactivation
- Releases intraneuronal norepinephrine into the synapse, also weakly but directly activates all adrenergic receptors
9. Ephedrine and drugs that act in s imilar ways or cause s imilar effects have a variety of therapeutic Given the background information provided for this patient, and the timing of ephedrine administration on the medication administration record, what i s the most l ikely reason why the ephedrine was given?
- Cause bronchodilation so mechanical support of ventilation would be easier
- Counteract CNS depression caused by the induction agents
- Inhibit s inoatrial and atrioventricular nodal automaticity to terminate or prevent anesthesia-related cardiac arrhythmias
- Lower heart rate that was raised excessively by the anesthetic drugs
- Raise blood pressure that was lowered excessively by the induction agents
10. Assume, hypothetically, that the surgery had to be done The patient had been taking another drug—still in her ci rculation at usually effective concentrations—that weakened but did not completely eliminate all of ephedrine’s peripheral autonomic effects. Which drug(s) would be most l ikely to do that?
- Atenolol (or metoprolol)
- Cocaine or a tri cyclic antidepressant (eg, imipramine)
- Trimethaphan (or hexamethonium)
- Pargyline (or a s imilar nonselective MAO inhibitor)
11. Shortly after the surgical wounds were closed and dressed, and right before the patient was transferred to the postanesthesia care unit (PACU), she received What was the reason for which i t was given?
- Raise and support blood pressure during recovery
- Raise or otherwise control bradycardia upon recovery from anesthesia
- Restore normal neurotransmission in the brain, s ince i t had been suppressed by the induction and anesthetic agents
- Reverse skeletal neuromuscular blockade/paralysis
- Suppress urinary bladder function to reduce the ri sk of postoperative bladder incontinence
12. The patient got her dose of glycopyrrolate mere seconds before the neostigmine was This i s done routinely in thousands of surgeries in which the drugs used are identical or at least very s imilar to those used here. To which pharmacologic class does glycopyrrolate most l ikely belong?
- α-Adrenergic agonist
- Antimuscarinic (atropine-like)
- Cholinesterase inhibitor
- Muscarinic receptor agonist
- Nicotinic receptor (skeletal muscle; NM) agonist
13. The patient in the case presented here was not facing any emergent or imminently l i fe-threatening problems, so skeletal muscle paralysis and intubation were relatively straightforward procedures, not at all Now assume, hypothetically, that emergency intubation was required, and succinylcholine (SuCh) was used because of i ts very rapid onset of action. Assume further that a s low infusion of SuCh was used to maintain paralysis throughout the procedure; blood levels of the drug were kept well in the therapeutic range; no curare-like (nondepolarizing) blocker was used; and the patient had no genetic or other factors that would affect the drug’s pharmacokinetics or action. When the surgery i s done, what drug would be given to reverse succinylcholine’s effects?
14. Now assume this patient received bethanechol several hours after her abdominal surgery, after effects of all the drugs used intraoperatively, except for morphine and ketorolac (analgesics) had worn Her heart rate fell s l ightly and she experienced some wheezing. Which word or phrase most l ikely accounts for or describes these cardiac and pulmonary responses?
- Expected s ide effects
- Parasympathetic ganglionic activation
- Reflex (baroreceptor) suppression of cardiac rate
- Undiagnosed asthma
15. Until recently the drug ri todrine has been used to suppress uterine contractions in some women who are in premature Side effects of the drug include ri ses of heart rate and increases in the force of contraction of the heart. High-output heart failure (caused by excessively increased cardiac output) and pulmonary edema have occurred, and in some cases the outcome has been fatal. Ritodrine also causes bronchodilation. It has no vasoconstrictor effects, nor any effects on the s i ze of the pupil(s) of the eye(s). The description most closely fi ts the characteristics of what class of drugs?
- α-Adrenergic agonist
- Atropine-like/antimuscarinic drug
- β-Adrenergic agonist
- β-Adrenergic blocker
- Muscarinic receptor agonist (parasympathomimetic)
16. A patient with a history of asthma experiences s ignificant bronchoconstriction and urticaria, and drug-induced histamine release i s a main contributor to these Which drug i s most l ikely to have caused these problems—not because i t has any bronchoconstrictor or histamine agonist effects in i ts own right, but because i t quite effectively releases histamine from mast cells?
17. During surgery the anesthesiologist administers trimethaphan, classified as an autonomic ganglionic blocker to an anesthetized What would you expect in response to this drug?
- Bradycardia mediated by activation of the baroreceptor reflex
- Increased GI tract motility, possible spontaneous defecation
- Increased salivary secretions