Ch. 22: Neuromuscular Blocking Agents Flashcards

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1
Q

NMBA Physiology

A
  • Cholinergic nicotonic receptor postsynaptic
  • ACH in presynaptic cell
  • AcetylCholinesterase and reuptake clear the synapse.
  • Succinylcholine is a depolarizer.
  • Rocuronium & Vecuronium are non-depolarizing and compete with ACh for the receptor.
  • Neostigmine, edrophonium and pyridostigmine inhibit ACHE
  • Sugammadex is a Rocuronium reversal agent.
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2
Q

Succinylcholine

A

1.5 mg/kg 45 second onset 6-10 min duration.

  • SCh is 2 ACH connected by Ester
  • Stimulates all Nicotinic and muscarinic cholinergic receptors. Parasympathetic and sympathetic.
  • Broken down by PseudoCholinesterase in plasma and liver. Thus bigger doses given for RSI.
  • Repeat doses can cause bradycardia, esp kids
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3
Q

Succinylcholine Contraindications

A
  • Personal or FH of malignant hyperthermia
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4
Q

SuccinylCholine Dose

A
  • 1.5mg/kg normally.
  • If poor circulation 2mg/kg
  • IM 4mg/kg but will be slower incomplete onset requiring BVM.
  • If just estimating the weight it’s safer to go higher than lower.
  • Age less than 10 2mg/kg. Less than 1 year often give atropine along with.
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5
Q

SuccinylCholine Adverse Effects

A
  • Fasciculations: May cause increased ICP!
  • Hyperkalemia: In upregulated immature ACH receptors.
    • BURNS after 3 to 5 days.
    • Denervation after 3 days: SCI, stroke, GBS, ALS and MS
    • Crush injury 3 days to 6 months.
    • Sepsis: After 3 days.
    • Myopathy: Esp kids w unknown heriditary myopathy.
    • Hyperkalemia: Only ESRD, AKI w arrhythmia.
  • Bradycardia: Multiple doses
  • Prolonged NMB.
    • Acquired PCHE deficiency liver disease, cocaine use, pregnancy, burns, BCP, Reglan, bambuerol or esmolol.
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6
Q

Malignant Hyperthermia

Succinylcholine

A

TREATMENT:

  • Dantrolene 2.5 mg/kg IV q 5 min. Max 10mg/kg till muscle regidity improved.
  • Monitor K, ABG

Signs:

  • Muscle Rigidity
  • Autonomic instability
  • Hypoxia
  • Hypotension
  • Lactic acidosis
  • Hyperkalemia
  • Myoglobinemia
  • DIC
  • Hyperthermia LATE!!
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7
Q

Trismus/Masseter Muscle Spasm

SuccinylCholine

A
  • Treat with Nondepolarizing NMBA
  • Consider underlying Malignant Hyperthermia
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8
Q

Competitive Neuromuscular Blocking Agents

Rocuronium & Vecuronium

A

Rocuronium

  • 1-1.2 mg/kg
  • 60 sec onset
  • 40-60 min duration

Vecuronium

  • 0.01 mg/kg prime 3 min 0.15 mg/kg GO
  • 75-90 sec onset
  • 60-75 sec duration
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9
Q

Competitive Neuromuscular Blocking Agents

Pharmacology

A
  • Block one or both alpha subunits of receptor
  • ACHE inhibitors cause reacumulation of ACH
    • Neostigmine 0.06 to 0.08 mg/kg
    • Atropine 0.01mg/kg to prevent the excessive salivation and nausea of neostigmine.
  • Sugammadex i Rocuronium reversal.
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10
Q

Competitive NMBAs

Indications & ContraIndications

A
  • Myasthenia patients may have longer paralysis
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11
Q

Competitive NMBA

Dosage

A
  • Rocuronium 1 to 1.2 mg/KG
    • Onset 60 seconds
  • Vecuronium Priming 0.01 mg/kg
    • 3 min later 0.15mg/kg.
  • For ongoing paralysis
    • Vecuronium 0.1mg/kg
    • Pancuronium 0.1mg/kg
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12
Q

Competitive NMBA

Adverse Effects

A
  • Pancuronium tachycardia.
  • Competitive are slower and longer than SCh
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