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Pharm Fall 2019 > Ex4 Reversal Agents > Flashcards

Ex4 Reversal Agents Flashcards

1
Q

Ganglia

A

group of nerve cells forming a nerve center, especially one outside brain/spinal cord

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2
Q

in both spine + brain, back (posterior) is always

A

sensory

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3
Q

in both spine + brain, front (anterior) is always

A

motor

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4
Q

mnemonic for PNS

A 
SAME DAVE
sensory-dorsal
afferent-afferent
motor-ventral
efferent-efferent
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5
Q

site of action for NMBAs

A

NMJ in skeletal muscle (somatic/voluntary) portion of efferent peripheral pathways

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6
Q

thoracolumbar ANS

A

sympathetic

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7
Q

craniosacral ANS

A

parasympathetic

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8
Q

effects of thoracolumbar NS

A

fight/flight/fright

  • redistribution of blood flow from vicera to skeletal muscle
  • increased cardiac fxn
  • decreased salivation
  • pupillary dilation (mydriasis)
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9
Q

effects of craniosacral NS

A

rest + digest (maintenance of fxns)

  • digestive fxns (increased salivation/mucus secretion, GI motility)
  • GU fxns
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10
Q

receptors in ANS are classified by

A
  1. neurotransmitters with which they react

2. described in terms of location (pre/post-synaptic)

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11
Q

adrenergic receptors react with

A

NE or Epi

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12
Q

adrenergic receptors are subdivided into

A

alpha1, alpha2, beta1, beta2

also dopaminergic receptors (D1-D5)

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13
Q

cholinergic receptors react with

A

ACh

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14
Q

cholinergic receptors subdivided into

A

muscarinic, nicotinic

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15
Q

Cholinergic nerves include

A

-all motor nerves that innervate skeletal muscle (somatic)

  • all preganglionic para/symp neurons
  • all postganglionic parasymp neurons
  • some postgangl symp neurons: sweat glands/certain blood vessels
  • preganglionic symp neurons that originate from grtr splanchnic nerve + innervate adrenal medulla
  • central cholinergic neurons
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16
Q

most organs have _____ innervation

A

dual (symp + parasymp)

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17
Q

anticholinergic Rx combine _____ with ____ receptors to compete with _____

A

combine reversibly with
muscarinic receptors
to compete with ACh

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18
Q

antimuscarinic Rx may enhance _____ activity

A

sympathetic

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19
Q

antimuscarinic Rx block all ______ effects

A

muscarinic

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20
Q

DOC - tx of reflex bradycardia

A

Atropine

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21
Q

tx of anticholinergic syndrome

A

physostigmine 15-60 mcg/kg IV

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22
Q

causes of anticholinergic syndrome

A

scopolamine

atropine

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23
Q

s/s anticholinergic syndrome

A

restlessness, somnolence, hallucinations, unconsciousness

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24
Q

atropine - caution in patients with

A

narrow angle glaucoma
prost hypertrophy
bladder neck obstruction

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25
Q

atropine uses

A

premedication- antisialogogue
tx for bradyarrhythmias
minimize effects of anticholinesterases
potent effects on heart/bronchial smooth muscle

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26
Q

how to minimize effects of anticholinesterases

A

add atropine, scopolamine, or glycopyrrolate

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27
Q

atropine premedication dosage

A

0.01-0.04 mg IM

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28
Q

max dose atropine

A

up to 0.4-0.6 mg total (adults)

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29
Q

max dose atropine w/ edrophonium

A

10mcg/kg

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30
Q

scopolamine premedication dose

A

0.4-0.6 mg IM

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31
Q

scopolamine - caution in

A

patients with:

narrow (closed) angle glaucoma, prost hypertrophy, bladder neck obstruction

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32
Q

additional use for scopolamine

A

prevention of PONV + motion sickness

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33
Q

glycopyrrolate premedication dose

A

up to 0.3mg IM

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34
Q

glycopyrrolate DOA

A

2-4 hours after IV adm

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35
Q

glycopyrrolate effects

A

increased HR

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36
Q

glycopyrrolate max dose

A

up to 0.01-0.012 mg/kg IV

with neostigmine or pyridostigmine

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37
Q

effect of anticholinesterase administration

A

massive parasympathetic response

38
Q

actual s/s of anticholinesterase administration

A 
salivation
weeping
wheezing
vomiting
urinating
defecating
seizing
39
Q

only endogenous compound that causes simultaneous bradycardia/hypotension

A

ACh

40
Q

muscarinic effects of ACh are similar to

A

vagal stimulation

41
Q

effects of ACh

A
  • generalized vasodilation (including cor/pulm circ)
  • negative chrono/dromotropic effects
  • inhibition of NE release from adrenergic nerves
  • smooth muscle contraction (bronch/int/gu)
  • relaxation of sphincters
  • contraction of iris
  • lacrimal, trach/bronch, salivary, dig, exocrine secretion
42
Q

primarily used for reversal of residual NMB by NDMRs

A

anticholinesterases (or cholinesterase inhibitors)

43
Q

goal of anticholinesterases

A

inhibition of AChE (“true cholinesterase”)

44
Q

when is reversal appropriate?

A

SAFE - only after evidence of spontaneous recovery from NDMRs

45
Q

what must be present in order to reverse with anticholinesterases?

A

a single twitch on TOF

2/4 TOF = better

46
Q

in absence of NDMRs, what can anticholinesterases produce?

A
  • fasciculations of skeletal muscles

- excess ACh may cause desensitization after admin

47
Q

cholinergic crisis/anticholinesterase OD

A

often by organophosphate insecticides

48
Q

cholinergic crisis/anticholinesterase OD s/s

A 
bradycardia, miosis, abdominal cramps
loss of bowel/bladder control
weakness, confusion, ataxia
coma, seizures, vent depression 
SLUDGE
49
Q

SLUDGE mnemonic

A

Salivation, Lacrimation, Urination, Defacation, GI upset, emesis

50
Q

Tx: cholinergic crisis

A

supportive (intubate/mech vent)
anticholinergic rx
administration of AChE reactivator (pralidoxime)

51
Q

MOA Pralidoxime

A

antagonizes CNS effects of excessive ACh

52
Q

effects of anticholinesterases

A

primarily reflect muscarinic effects

  • bradycardia/decreased SVR
  • salivation/hyperperistalsis
  • bronchial secretions/bronchoconstriction
  • miosis
53
Q

antimuscarinic drugs are not effective where?

A

NMJ

54
Q

neostigmine dosage

A

up to 0.07mg/kg (no more than 5mg total)

55
Q

who should not receive neostigmine?

A

patient with profound NMB

56
Q

pt with no twitches but + tetanic facilitation

A

no reversal

57
Q

neostigmine peak

A

10 minutes

58
Q

neostigmine DOA

A

> 1 hour

prolonged in CRI/CRF

59
Q

if incomplete reversal at peak of neostigmine

A

you MUST wait for full recovery prior to extubation (take patient to PACU intubated)

60
Q

preferred antimuscarinic given with neostigmine

A

glycopyrrolate d/t slower time to onset

61
Q

neostigmine effect on elderly/peds

A

more sensitive to effects, rapid onset, smaller dose

elderly only: prolonged DOA

62
Q

pyridostigmine is ______ as potent as neostigmine

A

20%

63
Q

pyridostigmine dosage

A

up to 0.35 mg/kg

up to 20mg in adults

64
Q

pyridostigmine onset

A

10-15 minutes

65
Q

pyridostigmine DOA

A

> 2 hours

prolonged in CRI/CRF

66
Q

Endrophonium dosage

A

up to 1mg/kg

67
Q

Endrophonium onset

A

1-2min

*fastest in class

68
Q

Endrophonium + atropine

A

co-administered

69
Q

Endrophonium + glycopyrrolate

A

glyco administered several minutes prior

70
Q

Endrophonium DOA

A

> 1 hour in large doses

prolonged in CRI/CRF

71
Q

tx for anticholinergic toxicity caused by atropine/scopolamine

A

Physostigmine

72
Q

unique for physostigmine

A

tertiary amine group

*lipid soluble = only anticholinesterase that can access CNS

73
Q

large doses of physostigmine may cause

A

central cholinergic crisis

74
Q

physostigmine dosage

A

up to 0.03 mg/kg

75
Q

what should be available with physostigmine administration?

A

atropine + glco d/t bradycardia (infrequent)

76
Q

physostigmine onset

A

5 minutes

77
Q

physostigmine DOA

A

30-300 minutes

78
Q

physostigmine metabolism

A

plasma esterases

*unique for class

79
Q

physostigmine AEs

A

salivation, vomiting, convulsions

80
Q

echothiophate is used for

A

eye gtt
combines irreversibly w/ AChE
inhibits plasma cholinesterase, may prolong DOA SCh

81
Q

Sugammadex characteristics

A
  • modified gaba-cyclodextrin
  • 3d, hollow cone shape
  • hydrophobic cavity, hydrophylic exterior (drugs go in but not back out)
82
Q

Sugammadex MOA

A

encapsulates steroidal NMBA

Roc>Vec>Pan

83
Q

sugammadex is biologically _____

A

inactive

84
Q

sugammadex metabolism

A

biologically inactive, rapid excretion, does not bind to plasma proteins
75% eliminated thru urine
~70% excreted w/in 6h, > 90% in 24h

85
Q

sugammadex is capable of reversing _____ depth of NMBA induced by ____ or _____ to a TOF ratio of _____ within ____ (time)

A

any depth
roc/vec
> or = 0.9
within 3 minutes

86
Q

sugammadex is ineffective against

A 
Sux 
Benzylisoquinolinium NMBAs (miva/atra/cistracurium)
87
Q

Sugammadex dosage: RSI wtih Roc

A

16mg/kg

88
Q

Sugammadex dosage: TOF 0/4

A

4mg/kg

89
Q

Sugammadex dosage: TOF 2/4

A

2mg/kg

90
Q

Sugammadex AEs

A 
Anaphylaxis
Marked bradycardia
Residual blockade
Risk of coagulopathy
not recommended - severe renal impairment (CrCl < 30mL/min)

Pharm Fall 2019 (33 decks)

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