Apex- Neuromuscular blockers Flashcards
Which subunits MUST be occupied to open the nicotini receptor at the motor endplate?
A. Alpha and alpha
B. Alpha and gamma
C. Alpha and delta
D. Alpha and epsilon
A. Alpha & Alpha
What is the NMJ?
It’s a synaptic connection between a motor nerve and skeletal muscle.
Which is present on the neurons vs motor end plate/skeletal muscle?
Nm or NN
(which is 1 and 2)
Nm (N1) [1 n] - M for motor end plate
Nn (N2) [2ns] - N for neuron
What does a peripheral nerve stimulator actually do?
It sends an action potential to depolarize the axon terminal and release stores of ACH into the synpatic cleft
>sodium ions flood in
>cell is now more positive on the inside which
>opens CA+ ion channels
>calcium goes in and releases ACH into the synaptic cleft
What happens when ACH binds to the presynaptic nicotinic receptors?
It speeds up the release of ACH stores
What hydrolyzes ACH as soon as it diffuses away from it’s receptors?
acetylcholinesterase
What is ACH metabolized into?
Choline + acetate
>choline is recycled back into the presynpatic neuron and used to synthesize more ACH
>acetate diffuses away from the NMJ
How does sux work?
it binds to the post-synpatic nicotinic receptor and depolarizes the motor end plate
it mimics ACH but binds to the receptor for a much longer period of time
-so it depolarizes the motor end plate (muscle contraction) and then it can’t be stimulated again until sux dissociates away from the receptor
How is the action of sux terminated?
after it diffuses away from the nicotonic receptors at the motor endplate
How do non-depolarizers work?
They block the nicotonic receptors at the motor endplate and prevent ACH from binding
What happens when ACH binds to the 2 alpha subunits on the post synaptic nicotinic receptor?
sodium and calcium flood flood into the myocyte and K+ leaves
what happens when the myocyte is depolarized?
(meaning calcium and na have flooded inside)
>The sarcoplasmic reticulum releases calcium into the cytoplasm where it engages with myofilaments and initiates muscle contraction
What enzyme terminates the effect of ACH
acetylcholinesterase
All of hte following statements regarding extrajunctional nicotinic receptors are true EXCEPt:
A. it is opened by choline
B. an epsilon subunit replaces a gamma subunit
C. It opens for a longer period of time
D. Denervation allows for it’s proliferation
B. an epsilon subunit replaces a gamma subunit
*extrajunctional (extra post-synaptic nicotinic receptors have a gamma subunit instead of a epsilon subunit
*This structural change impacts how it responds to sux
What two things can lead to proliferation of extrajunctional nicotinic receptors?
(aka- upregulation?)
- Denervation
- Prolonged immobility
<2yo, stroke, burns “thermal injury”
The the absence of exgtrajunctional receptors, sux can transiently increase the serum K by __ - ___mEq/L for up to ____-____ minutes.
0.5-1 mEq/L
10-15 minutes
In the event of a denervation injury, sux is best avoided ______ hours following the injury up to how long after?
after 24 hours up to a year
Pt with upregulated extrajunctional receptors are (sensitive/resistant) to nondepolarizers.
Does this increase or decrease the potency of these drugs?
they are resistanct to non-depolarizers (more receptors that need coverage)
- reduced potency of the drug
- more is needed
Which is pathologic of the nicotinic receptor - gamma or epsilon
gamma = pathologic
(think gamma knife is required for pathologic things)
epsilon = normal
Conditions where sux is contraindicated (9)
- upper or lower motor neuron injury
- SCI
- Burns
- Skeletal muscle trauma
- CVA
- Tetanus
- Severe sepsis
- Muscular dystrophy
- Prolonged chemical denervation (mag, long term NMB infusion, clostridal toxin)
Fade during TOF stimulation is caused by:
A. agonism of the presynaptic nicotinic receptors
B. antagonism of hte presynaptic nicotinic receptors
C. Impaired presynaptic acetylcholine reuptake
D. decreased acetylcholine synthesis
B. antagonism of hte presynaptic nicotinic receptors (Nn)
Why do you get fade with non-depolarizers but no fade with depolarizers?
non-depolarizers = antagonists
>fade is from blocking the presynaptic Nn receptor which results in less release of ACH from the presynaptic nerve terminal
depolarizers = agonists
>agonism of the presynaptic Nm receptor mobilizes ACH stores and therefore wont produce fade
Acetylcholine is synthesized from _____ & _____ in the presence of what?
choline & acetyl CoA
in the presence of choline acetyltransferase (ChAT)
Identify the statement that BEST characterizes a phase 2 block following succinylcholine (select 2)
- fade with tetany
- post-tetanic potentiation is absent
- constant but diminsed response to double burst stimulation
- prolonged duration
-fade with tetany
&
-prolonged duration
(a phase 2 block occurs with excessive dosease of sux)
Does Sux produce a phase 1 or phase 2 block?
Phase 1 block
What distinguishes a phase 1 from a phase 2 block?
The presecne of fade
phase 1 block = no fade
phase 2 block = fade
nondepolarizers - phase 1 or phase 2 block?
phase 2 (+fade)
- think depolarizers = 1
- non-de polarizers = 2
2 circumstances where sux can produce a phase 2 block
high doses
infusion of it
T/F: a phase one block will result in post-tetonic potentiation
False- present with a phase 2 block
Idenify the MOST sensitive indicator of recovery form NMB
A. 4/4 twitches with no fade
B. TV 6ml/kg
C. VC > 20ml/kg
D. Inspiratory force better than -40cm h20
D. Inspiratory force better than -40cm h20
The best place to measure the onset and recovery of blockade
Muscle vs nerve
onset:
Nerve:
-Facial nerve
Muscle:
>obicularis oculi (closes eyelid)
>corrugator supercilii (eyebrow twitch)
recovery:
Nerve:
-Ulnar nerve or posterior tib nerve
Muscle:
- Adductor pollicis (thumb adduction)
- Flexor hallucis (big toe flexion)
Stimulation of the _________ nerve results in closure of the eyelid (which muscle)
Facial nerve
- obicularis oculi
- closes eyelid
- onset/intubation conditions- first to go, first to come back
(corrugator supercilii twtiches eyebrow)
Stimulation of the _________ nerve results in twitching of the eyebrown (which muscle)
facial nerve
- corrugator supercilii
- onset/intubating conditions
- first to go/first to come back
Stimulation of the _________ nerve results in adduction of the thumb (which muscle)
ulnar nerve
-adductor pollicis
-extubating conditions/return of airway function
-last to go, last to come back
Stimulation of the _________ nerve results in big toe flexion (which muscle)
posterior tibular nerve
- flexor hallucis
- extubating conditions/return of upper airway muscle function
- last to go, last to come back
Recovery from NMB is defined as a TOF ratio of what
>/= 0.9
T/F- the return of normal tidal volume is a poor endpoint for assessing the retun of neuomuscular function
true
-whoops do it all the time
4 best qualitative bedside tests of recovery and degree of blockade association
- sustained tetany > 5 seconds
- sustained head lif > 5 seconds
- Sustained hand grip same as pre-induction > 5 seconds
- pt’s ability to hold a gongue blade in his mouth agaisnt force (whos doing such things)
50% blocked/50% recovered
placement of TOF stickers- is it red to the head or red to the heart
red to the heart
T/F - NMB is defined as a TOF ratio of < 0.9
True
TV of 6ml/kg correlates with ___% of receptors still being occupied
80% still bocked
-only 20% recovered
TOF without fade correlates to ____% of receptors still being blocked
how much recovered
70% still blocked
only 30% recovered
VC >/= 20ml/kg correlates to ____% of receptors still being blocked
how much recovered
70% still blocked
only 30% recovered
What 2 tests correlate with 60% of receptors still being occupied and the pt only being 40% recovered?
Sustained tetanus @ 50hz without fade &
DBS with no fade
*so these are more accurate predictors of recovery compared to TOF without fade
identify the statement that demonstrates the MOST accurate understanding of SUX
A. HTN is a normal side effect
B. It’s an absolute contraindication with an open globe injury
C. Severe sepsis increases the risk of hyperkalemia
D. Masseter spasm warrents cancellation of the planned procedure
A. HTN is a normal side effect
B. It’s an absolute contraindication with an open globe injury
C. Severe sepsis increases the risk of hyperkalemia
D. Masseter spasm warrents cancellation of the planned procedure
- sux is not absolutely conraindicated with open globe injury; the risk of eye injury is low and securing airway is the top priority
- masseter spasm may be a warning sign of MH but it’s also a normal effect of sux. In the absence of other signs suggesting MH, the case may proceed
An inspiratory force better than -40cm H20 is associated with what % of receptors being blocked vs recovered
50% blocked and recovered
(a more negative number is better)
T/F- masseter spasm is a normal effect of sux
true
-given no other signs of MH, it’s okay to proceed with case
T/F- HTN is a nomal side effect of sux
True!
-news to me lol
Why are kids more susceptible to bradycardia with sux and when should you administer atropine before giving sux?
bc kids have a higher baseline vagal tone
-give atropine before sux if a second dose is required
T/F sux is safe for the renal failure patient
true- as long as they have a normal K level
What 5 things can sux increase?
- Heart rate
- BP
- K+
- Intraocular pressure
- Intracranial pressure
- Intragastic pressure
What is sux made of?
2 acetylcholine molecules bound together
Mechanism by which sux can cause bradycardia or asystole
What increases this risk and why?
by stimulating the M2 receptor in the SA node
a second dose of sux increases this risk thought to be due to accumulation of it’s primary metabolite- succinylmonocholine
Primary metabolite of sux
succinylmonocholine (accumulation with a second dose of sux can lead to bradycardia or asystole and can be prevented or relieved with an antimuscarinic)
Mechanism by which sux causes tachycardia and HTN (mainly in adults)
by mimicking the action of Ach at the sympathetic ganglia
Sux transiently increases IOP by ____ - _____mHg for up to _____minutes
5-15mmHg for up to 10 minutes
How can you midigate the risk of increased ICP with SUX
Giving a de-fasiculating dose of NDMR; however, now that sugammadex is available, might as well just give that lol
since sux causes the contraction of abdominal muscles which increases intragastric pressure, does this increase the risk for aspiration?
no- bc it also increases lower esophageal sphincter tone
Why does sux stay at the NMJ longer than acetylcholine?
Bc it’s metabolized by pseudocholinesterase which is in the plasma and has to be delivered to the NMJ whereas ACH is metabolized by acetylcholinesterase which is immediately available at the NMJ to metabolize it
What metabolizes acetylcholine vs sux?
Acetylcholine
- acetylcholinesterase
- true, type 1, genuine, specific cholinesterase (the real og)
SUX (+ mivacurium and ester LA’s)
- pseudocholinesterase
- false, type 2, plasma cholinesterase
+ butryrylcholinesterase