4 nmb Flashcards
When a phase 2 block with sux occurs
> 7-10 mg/kg. 30-60 min iv infusion
Best place to measure onset of blockade
Orbicularis oculi or corrugated supercilii, facial nerve
Best places to measure recovery from blockade
Adductor pollicis (thumb adduction) or flexor hallucis. Ulnar or pt nerve
NMB recovery= TOF
<0.9
TV: acceptable endpoint, max % receptors occupied
> 5ml/kg, 80
TOF: acceptable endpoint, max % receptors occupied
No fade, 70
VC: acceptable endpoint, max % receptors occupied
> 20 ml/kg, 70
Sustained tetanus, DBS: acceptable endpoint, max % receptors occupied
No fade, 60
Insp force: acceptable endpoint, max % receptors occupied
Better than -40 (more neg the better), 50
Head lift >5 sec, hand grip: endpoint, % receptors
Sustained 5 seconds, 50
Holding tongue blade: %occipied
50
How sux causes bradycardia, when to give atropine
M2 receptor on sa node, 2nd dose increases risk. Due to metabolite of sux. Atropine should be given to kids before 2nd dose of sux
How sux affects intragastric pressure, esoph tone, and barrier pressure at GE junction
Inc, raises lower esoph tone, and unchanged pressure at ge junction
Things attenuated by a defasciculating dose
Little to no benefit with IOP. Inc Intragastric pressure, ICP
Enzymes that metabolize acetylcholine 5
Type 1 cholinesterase, acetylcholinesterase, true cholinesterase, specific cholinesterase, genuine cholinesterase
Metab sux, miva, and ester LAs 5
Type 2 cholinesterase, butyrlcholinesterase, false cholinesterase, plasma cholinesterase, pseudocholinesterase
Pseudocholinesterase: made by what, when NM symptoms appear/when Serious
Liver. 60%, 20%
Drugs that reduce pseudocholinesterase activity
Reglan, esmolol, neostigmine, echothiophate, BC/estrogen, cyclophosphamide, MAOIs, nitrogen mustard
Co existing conditions that reduce pseudocholinesterase activity
Atypical pche, severe liver disease, chronic renal disease, organophosphate poisoning, burns, cancer, older, malnutrition, late state pregnancy
What dibucaine is
Amide LA that inhibits normal plasma cholinesterase but has no effect on atypical pche
What a nml v abnormal dibucaine test looks like
Normal= 80, dibucaine inhib 80% of pseudocholinesterase and a nml enzyme is present. Abn= 20, dibucaine didn’t inhib the pts pche and an atypical variant is present
Pche variant/dibucaine number/sux duration: typical homozygous, heterozygous, atypical heterozygous
70-80/5-10 min. 50-60/20-30 min. 20-30 4-8 hours
What will restore plasma pseudocholinesterase levels in a pt with an atypical variant
Ffp, whole blood, or purified human cholinesterase
In hyperkalemia: how to tx with stabilizing the myocardium
Ca cl 20 mg/kg or ca gluconate 60 mg/kg
Tx hyperkalemia by shifting k into cells
Glucose 0.3-0.5g/kg 10% sol, insulin 1u/5g glucose, na bicarb 1-2mmol/kg, hypervent, albuterol neb
How to enhance k elim
Lasix 1 mg/kg, volume resusc, HD
Who is at highest risk of myalgia with sux. Lowest rates of myalgia in who
Women > men, young adults, those who dont routinely work out. Lowest: elderly, preg, kids
Meds that dec the risk of myalgia w sux
Defasciculating dose, nsaids, lido 1.5, higher dose of sux. Not decreased by opioids
Conditions that lead to hyperkalemia w sux
ALS, Charcot Marie, duchenne’s (and rhabdo), GB, hyperkalemic periodic paralysis, MS, up reg of achrs (injury)
Conditions that are sensitive or resistant to sux
Sensitive: Huntington chorea. Resistant: MG
Conditions that are sensitive to NDMR
ALS, duchennes, GB, Huntington chorea, MS, MG, sometimes myotonic dystrophy
The dose to intubate is usually ______ the ed 95
3-4x
ETT dose, onset, duration: miva, cis, vec, atra
Miva 0.15 mg/kg 3.3 min 17 min. Cis 0.1/5min/45 min. Vec 0.1/2 min/45 min. Atra 0.5/3min/45 min
ETT dose/onset/duration: roc, panc
0.6/1.7 min/35 min. 0.08/3 min/85 min
How atracurium, cis, and miva are metabolized
Atra= 33% Hoffman and 66% plasma esterases. Cis= Hoffman. Miva= pseudocholinesterase
How Hoffman elim affected by ph and temp
Elim faster w alkalosis and hyperthermia. Elim slower with acidosis and hypothermia
Drugs that potentiate NMB
VA (des>sevo>iso>n2o), abx (aminoglyc, polymyx, clinda, tetra), antidysrhythmics (verap, amlodip, lido, quin), LAs, lasix, dantrolene, cyclosporine, tamoxifin
How lytes effect NMB
INC by: lithium and mag. Dec by calcium and K
NMB that cause histamine release
Atra, miva, sux
What ppl are allergic to that is in nmb
Quaternary ammonium groups
Highest to lowest likelihood of anaphylaxis
Sux > atra > cis > roc > vec
Test to see is anaphylaxis has occured w nmb
Tryptase
TOF ratio assoc with aspiration
<0.9
