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BCPS Exam > Critical Care: Neuromuscular Blockers > Flashcards

Critical Care: Neuromuscular Blockers Flashcards

1
Q

What is the typical use of neuromuscular blockade in ICU

A
  1. Intubated patients with severe respiratory failure

2. Despite optimization of analgesia, sedation and ventilator management

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2
Q

List two common kinds of severe respiratory failure in the ICU

A
  1. Acute respiratory distress syndrome

2. status asthmaticus

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3
Q

Recent data suggest that early empiric neuromuscular blockade in patients with severe ____ is beneficial

A

ARDS

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4
Q

Neuromuscular blockers are also used as adjunctive agents to control ________ in patients with neurologic injury

A

Neuromuscular blockers are also used as adjunctive agents to control SEVERE INTRACRANIAL HYPERTENSION in patients with neurologic injury (e.g. traumatic brain injury)

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5
Q

What is the role of neuromuscular blockers in ventilators

A
  1. Neuromuscular blockers are typically used once efforts to facilitate ventilation have failed
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6
Q

What are modes of ventilation failure (3)

A
  1. Poor oxygenation
  2. Dyssynchrony
  3. High intrathoracic pressures that put the patient at risk for barotrauma
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7
Q

Summarize uses of NMBs in critical careq1.

A
  1. Help with ventilators
  2. Help with intracranial hypertension
  3. Help with shivers for therapeutic hypothermia
  4. Tetanus
  5. Decrease movement during procedures
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8
Q

NMB should only be used once __ and ___ goals are met

A
  1. Analgesia

2. Sedation

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9
Q

What dosing strategy should be used for sedatives used in conjunction with an NMB

A

Continuously infused sedative

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10
Q

What properties should sedatives that are used with NMB have?

A

Amnestic (e.g. benzodiazepines, propofol)

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11
Q

What sedative does not provide depth of s edation required for NMB infusion?

A

Dexmedetomidine

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12
Q

What is role of analgesics in NMB

A
  1. Analgesics can also be used as needed in patients with pain
  2. Many practitioners insist on the combination of a sedative and an analgesic in paralyzed patients
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13
Q

Patients should be provided with ______ while paralyzed

A

Lubricating eye drops

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14
Q

List four neuromuscular blocking agents

A
  1. Pancuronium
  2. Vecuronium
  3. Atracurium
  4. Cisatracurium
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15
Q

List six concerns with neuromuscular blockade

A
  1. Can mask seizure activity
  2. Critical illness poly-neuromyopathy
  3. Mask insufficient analgesia and sedation
  4. Increase risk of VTE
  5. Increase risk of skin breakdowna nd decubitus
  6. Corneal abrasions
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16
Q

How to prevent corneal abrasions

A

Apply ophthalmic ointment or drops to eyes every 6-8 hours

17
Q

Why is it important for therapeutic paralysis must be carefully considered and reevaluated every day?

A

Risk of critical illness poly-neuromyopathy (prolonged muscle weakness)

18
Q

What is a strategy to reevaluate NMB?

A
  1. Regularly discontinue the drug (e.g. once daily)
  2. assess sedation / sedative dose
  3. Assess need for continued blockade (does it meet a ventilator failure condition?)
  4. Assess dose of paralytic (did it wear off at expected time?)
19
Q

What NMBs is it more imporant to assess dose of paralytic?

A
  1. Pancuronium and vecuronium

2. Longer half-life AND dependence on end organ clearance.

20
Q

What is TOF used for with NMB?

A

To guide dosing

21
Q

How is TOF performed for NMB?

A
  1. four electrical impulses applied to ulnar or facial nerves
  2. Obatin baseline TOF: usually one twitch per impulse (4/4 twitches)
  3. Goal TOF is 1-2/4 twitches which indicates 85%-90% receptor blockade.
22
Q

What are two technical problems that limit accuracy of TOF

A
  1. Perspiration

2. Tissue edema

23
Q

Pancuronium, vecuronium, atracurium, cistracurium, prolonged in renal failure?

A
  1. Pancuronium: Yes
  2. Vecuronium: Yes
  3. Atracurium: No
  4. Cisatracurium: No
24
Q

Pancuronium, vecuronium, atracurium, cistracurium, prolonged in hepatic failure?

A
  1. Pancuronium: Yes
  2. Vecuronium: Yes
  3. Atracurium: No
  4. Cisatracurium: No
25
Q

Pancuronium, vecuronium, atracurium, cistracurium, duration of effect (hours)?

A
  1. Pancuronium: Atracurium (0.25-0.5 hours)
  2. Cisatracurium (0.5-1 hours)
  3. Vecuronium (0.5-0.75 hours)
  4. Pancuronium (0.75-1.5 hours)
26
Q

Pancuronium, vecuronium, atracurium, cistracurium, tachycardia?

A

Only pancuronium

27
Q

Pancuronium, vecuronium, atracurium, cistracurium, hypotension?

A

Only atracurium, which is dose dependent

28
Q

What two interactions can potentiate or inhibit paralysis

A
  1. Drugs

2. Electrolyte disorders

29
Q

What drugs can potentiate NMB?

A
  1. Corticosteroids
  2. Some ABX
  3. Some Antiarrhythmics
  4. Furosemide
  5. Lithium
30
Q

What ABX can potentiate NMB

A
  1. Aminoglycosides
  2. Clindamycin
  3. Tetracycline
  4. Polymyxins
31
Q

What antiarrhythmics can potentiate NMB

A
  1. CCB

2. type 1A antiarrhythmics

32
Q

What drugs can antagonize block

A
  1. Aminophylline
  2. Theophylline
  3. Carbamazepine
  4. Phenytoin (chronic)
33
Q

What electrolyte disorders can potentiate NMB

A
  1. High Mg2+
  2. Low Ca2+
  3. Low K+
34
Q

What electrolyte disorders can antagonize block

A
  1. High Ca2+

2. High r K+

BCPS Exam (34 decks)

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