flumazenil

[New CCU RN]

quick question.. i had a pt who was intubated for airway protection secondary to ugb... egd performed, ulcer cortorized and epi given and bleed was stable...we wanted to do a rapid extubation...no underlying lung disease but the patient was alert not enough....no following commands and no sustained eye contact, but had recieved alot of versed during the scope because of her agitation level..also elderly... i suggested a reversal agent bc the patient was a dni but agreed just for the scope and bc the only reason she was still intubated s/p the procedure was waiting for the versed to wear off... docs refused secondary to increased risk for seizure activity if given flumazenil....ive never heard of this... any thoughts on this??? just wondering...

she needed to get off the vent... ulcer was stable, hgb stable, no active bleeding and her gas was great... 7.39 41 344 yes 344 24.5 -.7 100% drawn on spontaneous breathing, 35% peep 5 psv 8

[New CCU RN]

just to update you, the patient was extubated the next morning after waking up from her versed dreams with no adverse affects

[New CCU RN]

cytochrome p450... isn't that the enzyme in your liver that if there is an increase in amount a drug will be metabolized faster (if metabolized by the liver) and if there is a decrease for whatever reason, the drug will be metabolized slower... correct me if i am wrong (and probably a simple answer to a complex concept)

[Brenna's Dad]

You pretty much have it right, New CCU RN. Cyctochrome P450 reactions are Phase One, oxidative and reduction reactions involving various liver enzymes responsible for drug metabolism. However, there are several differ types of P-450 enzymes which makes it a bit more complex.

Certain drugs are inducers or inhibitors of specific enzymes, which either decreases or increases the metabolism of other drugs that happen to be metabolized by the same enzyme.

For example, Grapefruit juice inhibits CYP1A2, one of the p-450 enzymes that metabolize warfarin. Therefore, theoretically at least, an individual who drank grapefruit juice on a daily basis would have decrease metabolism of warfarin and a higher INR. In a similiar manner, Ethanol is an inducer of CYP2E1, the P-450 enzyme that metabolizes acetaminophen. The combination of ETOH and acetaminophen are so dangerous, because the ETOH induces the enzyme resulting in increased metabolism of Acetaminophen and the increased production of the hepatotoxic metabolites.

[Tenesma]

now you know why tylenol is not a good choice for a hangover...

[kc ccurn]

now you know why tylenol is not a good choice for a hangover...

My thoughts exactly :chuckle : That is way over my head which is exactly why you are a CRNA and I'm not. Not trying to be a smart alec but can you also recite the coagulation pathway as well? I am really impressed!!!

[Brenna's Dad]

I understand the basics of the P-450 cytochrome system, but don't walk around knowing which enzymes inhibit/induce which drugs! (I had just reread an article since Tenesma's post stimualted some curiousity about this subject again.) I find the grapefruit juice and acetaminophen example interesting, since I never understood this as a RN.

Regarding the coagulation pathway, I did this for my pharmacy teaching project, so ya, I can recite it. But probably sooner than not, it will start to get foggy....

[Berliner]

Chok full of information! I now see where the chem/ o-chem review will be usefull, but other than oxidative etc rxns- can anybody else give me a short list of things to review. I don't feel like re-reading the whole book! :balloons: