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DA Orientation > 6- Neuromuscular Blocking Agents > Flashcards

6- Neuromuscular Blocking Agents Flashcards

1
Q

Where do NA+ ion bind when an action potential is undergoing?

A

The presynaptic neuron axon terminal membrane

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2
Q

What ion voltage gates are open after NA+ channels are open?

A

Ca2+

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3
Q

What does Ca2+ do?

A

triggers the fusion of acetylcholine vesicles with the presynaptic membrane

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4
Q

The binding of acetylcholine to the postsynaptic membrane chemically opens what gates?

A

Na+ gate channels that depolarize the postsynaptic membrane

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5
Q

What happens to acetylcholine in the synaptic cleft after the action potential?

A

Broken down by acetylcholinesterase into Acetyl CoA + choline

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6
Q

What happens to the acetylcholine in the presynaptic cell after an action potential?

A

Synaptic transmission (acetylcholine and vesicles are recycled

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7
Q

What happens to acetylcholine once they enter the synaptic cleft?

A

Bind to receptors on the postsynaptic membrane

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8
Q

The action potential travels along what tubule

A

T-tubules

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9
Q

What happens after the action potential travels along the T-tubules?

A

It induces the Sarcoplasmic reticulum

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10
Q

What is released once the action potential induces the Sarcoplasmic reticulum?

A

More Calcium

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11
Q

What does Ca2+ bind to?

A

Troponin

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12
Q

What does Troponin relieve?

A

It relieves tropomyosin from the myosin binding site

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13
Q

How does myosin bind to actin?

A

Via ATP

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14
Q

What happens when ATP is hydrolyzed?

A

a power stroke occurs

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15
Q

During a power stroke, what is brought together?

A

Z lines

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16
Q

When Z lines are brought together what does it lead to?

A

Muscle contraction

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17
Q

During a normal action potential what neurotransmitter binds to the Nicotinic ACh-receptor?

A

ACh

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18
Q

During a (depolarizing muscle relaxant) action potential what neurotransmitter binds to the Nicotinic ACh-receptor?

A

Depolarizing muscle relaxant

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19
Q

What breaks down the depolarizing muscle relaxant and where is it returned?

A

broken down by pseudocholinesterase and returned to the BLOOD

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20
Q

What type of drug is Succinylcholine?

A

Depolarizing NMBA

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21
Q

What is the onset of IV Succinylcholine?

A

30 - 60 seconds

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22
Q

What are the routes of administration of Succinylcholine and what dose?

A

IV 1 mg/kg

IM 4 mg/kg

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23
Q

To what receptors does Succinylcholine bind?

A

Nicotinic postsynaptic receptors

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24
Q

What signs are seen upon the binding of Succinylcholine to the Nicotinic receptors?

A

1- Depolarization

2- Fasciculation

3- Flaccid paralysis

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25
Q

True or False:

Fasciculation ceases when all nicotinic receptors are bound to nicotinic receptors?

A

True

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26
Q

What age group is at increased risk of muscle pain with muscular builds after SCh?

A

Adolescents

27
Q

What is the duration of Succinylcholine?

A

3-5 minutes

28
Q

What are the clinical effects of Succinylcholine paralysis?

A

1- Adductor pollicis (10 minutes)

2- Diaphragm (5 min)

29
Q

What is the first dose consideration seen with Succinylcholine?

A

Bradycardia

30
Q

What is the second dose consideration seen with Succinylcholine?

A

Asystole

31
Q

How do you attenuate to Succinylcholine induced Bradycardia and asystole? And what signs are sometimes seen?

A

Administer Atropine or glycopyrrolate

Increase in catecholamine release and tachycardia

32
Q

What type of trigger is Succinylcholine?

A

Malignant hyperthermia

33
Q

How does Succinylcholine lead to MH?

A

Increase in serum potassium by 0.5-1 mEq/L

Hyperkalemia

34
Q

What type of patients needs extra care with Succinylcholine?

A

Pts that aren’t normokalemic rental faliure patients

35
Q

What is a phase II block?

A

1- continuous activation of ACh receptors which leads to ongoing shifts of NA+ into the cell and K+ out of the cell

2- Receptors do not respond appropriately to ACh, neuromuscular blockade is prolonged

36
Q

True or False:

Succinylcholine is incriminated as the trigger of allergic reactions more often than any other drug used in anesthesia?

A

True

approcimately 1:5,000 - 1:10,000

37
Q

Abnormality of pseudocholinesterase activity leads to prolonged paralysis in two abnormal ways?

A

1- Hetrozygous -> 15 min more delay in paralysis

2- Homozygous -> 1-2 hours of delay
- Homozygous population is 1:3,000 - 1:10,000

38
Q

How is pseudocholinesterase abnormality tested?

A

Dibucaine number (genetic testing)

Normal 80

Hetro 50

Homo 20

39
Q

True or False:

Non-depolarizing and Depolarizing Neuromuscular blockers bind differently to the nicotinic receptors?

A

False

The only difference:

Depolarizing such as Succinylcholine is returned into the BLOOD

Non depolarizing such as Rocuronium is returned to the LYMPH

40
Q

Non-depolarizing agents are classed based on chemical structure into?

A

1- Aminosteriods (Rocuronium, Vecuronium pancuronium)

2-Benzylisoquinolinium (mivacurium, atracurium, cisatracurium)

41
Q

For pancuronium, what is the bolus dose, and where is metabolized?

A

0.05-0.1 mg/kg

(Nondepolarizing Aminosteriods)

renal

42
Q

For vecuronium, what is the bolus dose, and where is metabolized?

A

0.08- 0.1 mg/kg

(Nondepolarizing Aminosteriods)

Hepatic

43
Q

For Rocuronium, what is the bolus dose, and where is metabolized?

A

0.6 - 1 mg/kg

(Nondepolarizing Aminosteriods)

Hepatic

44
Q

For Atracurim, what is the bolus dose, and where is metabolized?

A

0.4- 0.5 mg/kg

(Nondepolarizing Benzylisoquinolinium )

Hoffmann reaction

45
Q

For Cisatracurium, what is the bolus dose, and where is metabolized?

A

0.1-0.2 mg/kg

(Nondepolarizing Benzylisoquinolinium )

Hoffmann reaction

46
Q

For Succinylcholine, what is the bolus dose, and where is metabolized?

A

1 mg/kg

(depolarizing)

Plasma cholinesterase

47
Q

How many stimuli are delivered and at what time/frequency for the Train of Four Monitoring?

A

4 stimuli

2HZ over 1.5 seconds

48
Q

What is the percent of blocked receptors for the Train of Four Count?

A

TOFC of 1= >95% of receptors blocked

TOFC of 2= 85-90% of receptors blocked

TOFC of 3= 80-85% of receptors blocked

TOF of 4= 70-75% of receptors blocked

49
Q

How is the estimated degree of the block calculated?

A

ratio of T4/T1

50
Q

Majority of Surgeries require what percent of block?

A

80%

TOFC of 3

51
Q

What are the clinical signs of the level of paralysis?

A

1- Sustained head lift = 50% blockade

2- Hand grasp= 50% blockade

3- TV > 5 ml/kg = 80% blockade or less

52
Q

What areas precede the adductor pollicis by 1-2 min following an NMBD?

A

Larynx and orbicularis oculi

53
Q

True or False:

Muscles with relatively high blood flows have faster onset and recovery?

A

TRUE

such as diaphragm, masseter, and laryngeal muscles

54
Q

True or False:

the effectiveness of reversal agents depends directly of the degree of recovery present and should be given on when 4 twitches are visible “ preferably measured at the adductor pollicis”?

A

TRUE

55
Q

Why isn’t the presence of spontaneous ventilation considered a sign of adequate neuromuscular recovery?

A

Because the diaphragm recovers earlier than the much more sensitive upper airway muscles

EX: Geniohyoid recovers on average at the same time as the adductor pollicis

56
Q

Reversal agents are divided into two types?

A

Anticholinesterases

Sugammadex

57
Q

What is the MOA of Anticholinesterases?

A

Impairs the breakdown and rate of ACh which in return allows the excess ACh to displace the non-depolarizing NMBA

58
Q

What is the dose of Neostigmine?

A

0.05 mg/kg

max 5mg

59
Q

When Neostigmine is given, Glycopyrrolate is given?

A

0.2 mg of Glyco for every 1 mg of neo

max 1mg

60
Q

Preceding NEO, Atrpine/ Edrophonium given, what crisis could result?

A

Acute cholinergic crisis

61
Q

How does Sugammadex work?

A

it encapsulates nondepolarizing steroidal NMBAs in a 1:1 ratio

62
Q

What should you tell your female patients after giving Sugammadex?

A

Decreased effectiveness of hormonal birth control

63
Q

what is the dose of Sugammadex?

A

Based on the depth of NMBA

TOF> 2 2mg/kg

TOF=1 4mg/kg

TOF=0 16mg/kg (in this case Roc can not be used for 24 hrs)

64
Q

what is the emergency dose of Sugammadex?

A

16mg/ kg

DA Orientation (6 decks)

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